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MTOLOFOT 0F_£Ki-JLTH
CONCEPT 7/ITH SPECIAL REFERENCE
TO_BASLJ_DSALfIH 3ERVIcIs_lN INDIA.
J
By
-
Dr. J.R.Bhatia
1.
Heury-R. zin.B r (1948) and P.Kutumbiah(1958) have put forth evidence
to suggest that in Emperor Ashokas1 tine,2000 year ago, official health
services for the people were regionalised and integrated at the point
of del ivory •
2.
Lord Dawson of penna (1920) set forth regioaalised health centre concept
which has. been experimented with in sone of the European and American cities
since the beginniig of the 20th Century Parry,R.E. (1949) has reviewed these
efforts. Following Dawson Report, a special Grovernmental Coi3missi.?n proposed
that comprehensive care units be established in regional patterns around base
hospitals in order to obtain maximum utilisation of personnel and resources,
without duplication.
3.
About the same time and following Russian Revolution in 198, health services
in Russia vzere completely reorganised on regionalised basis,with integration
Oi curative and preventive services at all levels and primary emphais on
-prevention of diseases, as corner-stones of the services. Details of these
services as they have developed to-date are available in WHO,public Health
paper No.35(1960).
4.
European Conference on Rural Hygiene(1931) defined health centre as
Institution for the promotion of health and welfare of the people in a given
area which seeks to achieve its purpose by grouping under one of or coordinating
m some other manner under the direction of the health officer, all the
health work of that area together with such welfare and relief organisations
as may be related to the general public health work”. The Conference
further recommended that where a modern public health organisation is to be
created in a new terri'toryi the health centre, as defined above,is the best
method of attain!ng the desired result^.
5.
Jacoci£s(1933) reviewed and elaborated the concept of demonstration health
health centres organised by Rockefeller Foundation in Ceylon and later in
India. These centres organised only preventive health services(The concept was
imported from city Health Centres in U.S.A.)
6.
John B.Grant started teaching health Centres in several Asian countries
including India(e.g.Singur).Special features of these centres vzere
comprehensive health services,use of these centre for education of physicians
and other members of health team and training of village youth to work as
voluntary health workers .Details of this concept are available in”Health Care
of the Ccmmunity”.
7.
The Shore Committee(1946) recommended a regi.nalised system of health
services in India, providing comprehensive health services based on health
centres and sub-centres in rural areas. A special feature of this report is
that it recommended that all health services be tax supported end manned
by fully salaried personnel. Another important feature of this report is the
emphasis on the production of ’’social physician”- a ’basic doctor’.
8.
Health Services in Britain(1968) describes the details of National Health
Services in ihngland which started in 1343, organised on the principle of
regionalisation, the service is comprehensive,tax supported and almost free.
Special feature is choice of physician by the patient and vice verse.lt is,
however, not as integrated or prevention oriented as USSR services.
Pot.O
- 2 Health Services in Europe (1965) describes Yugoslav Health -j-;ices
organised and developed in the fiftees. The servtes are con..renensi^
and integrated a«i based on the principle of regionali satior-.special
feature is coapulsory health insurance of the total popular
'Avy
interesting aspect is that the services are self-supporting, s.^f-Bk>.3X.g
and locally financed.
Dutt,P.Pu.(1962) describes development of Primary health centres in Iruia^
10.
inrediately after independence and in the ninteen fiftees ac.an integral
part ofconummity Development pragraarie, echoing ana elaboraoii^ tne
idea mentioned in para 4 above. This moveiaentimplemented the princi^.e of
regionalisation in the field of health for the first time, in contemporary
India experience with primary health centres has underlined die need xor
professional and administrative integration of health activities ano.
functions and for making the services sufficiently comprehensive.
11. Health Survey and Planning Committee(1962) found the quality of services
’the.Ging ci
organised by primary health centre inadequa'te
inadequate snd
and advised s'treng
strengtneaing
o±
existing PHCs. Before new centres are established. They also emphasised
y majr
ective^
for strengthening sub-divisional and district hospital so that
that td
t-. y
may eif...Cuizery
9.
1
function as referral centres.
12.
Chadha Committee (1963) heldthe view that maintenance phas': of national
C.D.C. Pro^raixn is the responsibility of the general health cerv- s,which snstli
be adequately strengthened particularly in rural a-eas.They recon sp ed integration
of nation C.D.C. programmes with basic health services, including _• .P. ,?“nj
suggested one multipurpose workers
per 10,000 population, to be increased
later to one for 5000 population .This concept and approach has
furtier
developed in ’’Integration of Mass campaigns against specific di-?< cos ir^o
General Health Services”.
Almost the same time National Family plannin. programme t
tea e?.tensi>n
13.
approach and suggested separate additional staff yor F.P.work in
areas.j-^is
staff was later increased.The details are available in F.r.Programje ox 1962-ou.
14.
Mukherjee Committee(1966) reviewed the ”1963 scheme” for basic health
services as also the new F.P. extension scheme and held that whereas health
services should be provided in an integrated manner and the workers should be
multipurpose for the basic health field, he can provide only in., erm at ion servicer
in the field of fanily planning.The Committee suggested a parallel hierarchy so
as to ensure promotion of F.P.mass campaign.
Master Plan(1970) noted regional and rural urban disparbieis in
15.
particularly in the matter of distributionl of doctors and hospital beds .They
pointed out"that there is close inter-dependence between medical profession,
health services and medical education and recomended that all these three. be
tackled simultaneously.They suggested that ’’reasonable” medical
:ilities be
provided in rural ereas within the remaining period of 4th plan,t^ “aking doctors
and beds to within”reascnable approach of the people”.By this ir
hop. shat
the country may see the beginning of an assurance,if not an insr.r .;ice, ‘- a icj-. . y
comprehensive health care for millions of families.
16.
National strategy on Health( 1972) and National Health Sch?
ror !?:urpx
Areas(1972) carried the concept further and gave concrete suggest-:ns for
implementatioruThey suggested 3 fold increase in the number of HCs,two-zolc increase
in the number of sub-centres and field staff,increase in no.of b^- s in rurm
areas to reach on bed per 1000 population,improved quality of s-.. "vi ces by
ensuring full staffing and provision of more drugs at pHCs.and hospital ess.
and utilising the services of .ractitioners of I.S.U. & Homeopathy, one ■ o-'’
2000 population,for easy accessibility of routine and minor tre lent
facilities.
Co/V)
C|. 7__
medico friend
circle
bulletin
MARCH 1.976
EVOLUTION OF THE EXISTING HEALTH
SERVICES SYSTEMS OF INDIA
D. BANERJI*
A Profile of the Policy Formulators and Health Admini
strators :After Independence, the health services system
of the country was shaped by the two key political
decisions of the new leadership. Following the poli
tical commitments made during the struggle for In
dependence. provision |of health services to the vast
masses of the people—particularly for those living in
rural areas—was made an important plank of the
Directive Principles for the State Policy of the Indian
Constitution 1 . The other political commitment which
turned out to be an even more sacred and of over
riding importance was to bring about the desired
changes in the health services system without making
any basic changes in the then existing machinery of
the government.
The personnel of the Indian Medical Service of
the British days and the “ Brown Englishmen ” were
called upon by the Indian leadership to provide the
initiative in shaping the proposed new health services
system for India. These personnel, who like those
of the Indian Civil Service, belonged to elite class
of administrators. They were former officers of
the British India Armed Forces who had opted
for civilian work. They were also trained in the
traditions of the western countries, Political independence brought to the fore two additional issues
which profoundly affect the cadre of the Indian
Medical Service. Firstly, the withdrawal by the British
officers after Independence caused a sudden vaccum
in their ranks. This came as a windfall to a number
of not so competent officers, who were catapulated
Go to the people
into positions of key importance simply because they
happened to become senior in the cader because of
the very large number of vacancies caused by the
departure of the British. Secondly, by adhering strictly
to the seniority rules, when the health services were
expanded very rapidly to meet the requirements of
the newly formulated health programmes, the admini
stration drew more and more from the relatively small
group of people who had entered the services in, say,
1930-35, 1935-40 or 1940-45 to meet the very rapidly
increasing manpower needs for key posts. As a
result, a large number of the key posts in the health
services got filled by persons, who, even from the
colonial standards, were not considered to be bright.
Such a massive domination of the organisation
by men who were trained in the colonial traditions
and whose claim to a number of vital posts in
development administration was based merely on their
being senior in the cadre, led to a virtual glorifica
tion of mediocrity, with all its consequences2 pp-55-57.
What was even worse, such a setting was inimical to
the growth and development of the younger genera
tion of workers. Often these young men had to pay
heavy penalties if they happened to show, on their
own. enterprise, initiative and imagination in their
* . This
work, Conformism often earned good rewards.
within
the
mediocrity
of
ensured perpetuation
organisatian.
# Chairman, Centre for Social Medicine
and Community Health,
Jawaharlal Nehru University, New Delhi-110057.
Because of their being inadequate for the job,
these Brown Englishmen went out of the way to
appeal foreign experts for help and the latter have
generously responded to such entreaties. A large
number of foregin experts were invited to play a
dominant role in almost every facet of the health
services system of the country3
Medical Colleges, Teaching Hospitals and other Medical
Care Facilities In Urban Areas
Two divergent forces in the country—availability
of relatively very much larger amounts of resources
for the health sector and perpetuation by the techno
crats, the bureaucrats and the political leadership of
the old privileged class, western value system of the
colonial days gave shape to a health service which
had a strong urban and curative bias and which
favoured the rich and the privileged.
It is significant that when the country had only
about 18,000 graduate physicians and about 30,000
licenciate physicians 4’ p- 35, one of the first major
decisions of the popular government of India in the
field of health was to abolish the three year post
matriculation licenciate course in medicine 5* p* 313.
While recognising “ the great lack of doctors ”, the
very large majority of the members of the Health
Survey and Development Committee (Bhore Committee),
probably strongly influenced by the recommenda
tions of the Goodenough Committee in the United
Kingdom ’ 6’ p* 340 asserted that resources may be
concentrated “ on the production of only one and
that the most highly trained doctor ” 6 pp- 339,349.
Committee had made elaborate recommendations
concerning the training of what it termed as the
“ basic doctor ” and stressed that such training should
include ‘ as an inseparable component, education in
community and preventive aspects of
medicine ” 6,pp* 355-359.
The Medical Council of India, a direct descen
dent of the Medical Council of Great Britain, which
is the statutory guardian of standards of medical
education in India, has issued repeated warnings
against reviving the licenciate course. The Health
Survey and Planning Committee of 1961 (Mudaliar
Committee ) 5 has also emphatically rejected the idea
of reviving such a short-term course because they
were convinced that the proper development of the
country in the field of health must be on the lines
of what we consider as the minimum qualification
for a basic doctor ” ( p.349). It went on to state :
India is no longer isolated and is participating in all
problems of international health. The WHO has laid
down certain minimum standards of qualifications. In
view of India being an active member, participating
2
in all public health measures on an international
basis, we think it will be unfortunate if at this stage
once more the revival of a short term medical course
is to be accepted” (p.349).
One of the saddest ironies of the medical education
system in India is that resources of the community are
utilised to train doctors who are not suitable for
providing services in rural areas where the vast majo
rity of the people live and where the need is so
desparate. By identifying itself with the highly expensive
and urban and curative oriented system of medicine
of the west, the Indian system actively encourages the
doctors to look down on the facilities that are available
within the country, particularly in the rural areas, and
they look for jobs abroad and thus cause the so-called
brain drain. As if that is not enough, till recently
these foreign trained doctors have been pressurising
the community to spend even much more resources to
attract some of these people back to the country by
offering them high salaried prestigious positions and
making available to them very expensive super sophisti
cated medical gadgets. These foreign trained Indian
specialists, in turn, actively promote the creation of
new doctors who also aspire to “go to the States”
to earn large sums of money and to specialise.
Emphasis on specialisation, incidentally, causes consi
derable distortion of the country’s health priorities
thus causing further polarisation between the haves
and the havenots.
Those who are unable to go abroad, they try to
settle down in private practice in urban areas, often
linking their practice with honorary or fullfledged jobs
in urban health institutions run by the government.
Only some government jobs are non-practicing. As a
result of such considerations, a desparately poor
country like India finds itself in a paradoxical position
in relation to the distribution of the doctors in the
country : the urban population, which forms 20 per
cent of the total, accounts for 80 per cent of the doctors.
To be sure, pretending to follow the recommen
dations of the Bhore Committee, soon after Indepen
dence upgraded departments of preventive and social
medicine were created in medical colleges, at the
instance of the government and of the Medical Council
of India, to act as spear-heads to bring about social
orientation of medical education in India. However,
as in the case of so many other ambitious and morally
lofty government programmes, concurrently it was also
ensured that the very spirit of this programme is stifled,
if not totally destroyed, by actively discouraging in
various ways its actual implementation. For instance
instead of mobilising the finest brains in the profe
ssion to bring about social orientation, most of the
Live among them
positions in the departments of preventive and social
midicine were filled by the discards, who were often
found intellectually inadequate to get into the highly
competetive and prestigious clinical disciplines, or even
the paraclinical disciplines. This gave enough oppo
rtunities to the threatened foreign trained super
specialists to ridicule the entire discipline of preventive
and social medicine and bring it down almost to the
bottom of the prestige heirarchy of disciplines in a
medical college17. Significantly, the political leaderships^
—the ministers and legislators, who are beholden
to these super specialists for their personel needs of
various kinds, winked at this systematic desecration
of the philosphy of social oriematien of medical
education in the country18.
Along with the very rapid proliferation of very
expensive teaching hospitals for medical colleges, each
having a number of specialities and super specialities,
a number of general hospitals were established in urban
areas. The number of hospital beds shot up from
113,000 in 1946 15, p- 72. to the present figure of
330,000 19, p- 34. There has also been a rapid increase
in the number of dispensaries for providing curtive
services to urban populations. There were over 1807
urban dispensaries in 1966 10, p- 12°. The development
of medical colleges, teaching hospitals and other
hospitals and medical care facilities has accounted for
a large chunk of the investment for health services in
the country’s Five Year Plans 51 p- 76’ 14’ p- 18. The
recurring cost for these institutions accounts for over
three fourths of the annual health budget of a
State 1b p*5.
Mass Campaigns against some major Health Hazards :
The fact that despite their obvious over-riding
importance, preventive services have received a much
lower priority in the development of the health service
system of India provides an insight into the value
system of the colonels of the Indian Medical Service,
the British trained bureaucrats of the Indian Civil
Service and, above all, the value system of the political
leadership of free India. The colonels did not appear
to relish the prospects of dirtying their hands—getting
involved in problems which required mobilisation of
vast masses of people living in rural areas. The rural
population raised in the minds of these decision
makers the spectre of difficult accessibility, dust and
superstitious, ignornt, ill-manered and illiterate people.
Therefore, when they were impelled to do some
preventive work in rural areas, characteristically,
they chose to launch military style campaignr against
some specific health problems.
Undoubtedly, because of the enormous devasta
tion caused by malaria till the early fifties, this disease
Love them
deserved a very high priority. But the programme
became a special favourite of the colonels not only
because it required relatively much less community
mobilisation, but it also provided them with an
opportunity to build up an administrative frame work
to launch an all out assault on the disease in a
military style—in developing preparatory attack, conso
lidation and maintenance phases, in having “ unity of
command ”, and surprise checks and inspections and
in having authority to “ hire and fire
Significantly,
some of the followers of the colonels went so far as
to compare the malaria campaign with a military
campaign 12. Another enthusiast for military methods
has written an entire book 13 with a preface from
the late Prime Minister Jawaharlal Nehru describing
of the growth of the health services in independent
India as if he is describing a military campaign.
Experience of implemenation of India’s National
Tuberculosis Programme brings sharply into focus
the limitations of this military approach to developing
a health service system for the people of this country.
On the basis of a series of operational research
studies 14, it was demonstrated that it is possible to
offer facilities for diagnosis and treatment to over a
million and a half of sputum positive cases who are
known to be actively seeking help for their illness
from over 12,000 to 15,000 health institutions in
various parts of the country. But because of failure
of the programme administrators to develop a sound
health delivery system on a permanent basis for the
rural populations of the country, more than a decade
after the launching of the programme, less than one
fifth of these sputum positive cases, who .have an
active felt need, are being dealt with by the programme
organisation 14. This provides an example as to how
the militaristic urban privileged class value system
has come in the way of building a health service
system to meet even some of the very urgently felt
needs of the people of the country.
After some pilot projects, a National Malaria
Control Programme was launched with the help of
the United States Technical Co-operation Mission, the
World Health Organisation and the United Nations
International Children’s Emergency Fund (UNICEF)
in 1953 to cover all the malarious areas of the country,
then involving a population of 165 million 13' p’ 1U.
It achieved a phenominal success; for instance, the
number of malaria cases for every 100 persons visiting
hospitals or dispensaries declined from 10.2 percent
in 1953-1954 to 4.0 percent in 1958-1959 13’ p’ 112.
This success emboldened the administrators to think
in terms of totally eradicating the disease from the
country, once and for all. The danger of the mosquitos
developing resistance to the main weapon for malaira
_______——-y
control, DDT, was given as additional reason for
embraking on the eradication programme. Besides,
pressure was also put on India by foreign consultants
from WHO and elsewhere to embark on the eradi
cation programme as it was to become a part of the
global strategy propounded by the WHO 13’ pIt was also stated, to give economic grounds for
the decision, that while the control programme was
estimated to cost about Rs. 270m in the second Five
Year Plan ( 1956-1957 and 1960-1961 ) and Rs. 350m
during the Third Plan ( 1961-1962 and 1966-1967 )
and thereafter continued to remain a heavy item of
expenditure, “ the cost for the eradication progra
mme was estimated to be Rs. 430m in the last
three years of the Second Plan and Rs. 580m for
the entire Third Plan with the annual expenditure
becoming negligible thereafter ” 13’ p- 113. The imme
diate successes of the National Malaria Eradication
programme were even more spectacular, but a
disastrous snag developed in implementing the main
tenance phase of the programme 15,pp- 4-6. It turned
out that among other factors, because of preoccupation
of the administrators with specialised mass campaigns
against malaria and other communicable diseases, they
had not paid adequate attention to building a
permanent health service system— the so-called health
infrastructure— strong enough to carry on the malaria
surveillance work effectively at the village level. This
has been responsible for a series of setbacks to the
National Malaria Eradication Programme, resulting
in the reversion, at a very considerable cost, of large
segments of the maintenance phase population on to
consoldation or attack phases. Instead of getting rid
of malaria once and 'for all by 1966, as it was
envisaged in the late fifties, 40 per cent of the popula
tion is still to reach the maintenance phase 15, p- 5.
The National Malaria Eradication Programme thus
continues to drain huge quantities of scarce resources
even today thus making it even more difficult to
find resources to develop the health services
infrastructure.
During the last four years, for instance, less than
3 percent of the additional population (9.4 units) has
entered the maintenance phase 15’p- 5. Meanwhile
the country is forced to set aside huge chunks of its
very scarce recources to prevent the programme from
sliding still further. As against the envisaged expendi
ture of Rs. 1,015 m, the National Malaria Eradication
Programme has thus far sucked in over Rs. 2,500 m,
ig, P. 22.5 and 2°, Jn addition? Rs> 967m have been
set aside for it for the next five years 15’ p- -3--4
and even this allocation might have to be raised still
further. In spite of this the chances of eradicating
malaria in the foreseable future does not appear to
4
be very bright. So the country will be compelled to
keep on pouring in resources on this programme to
see that the disease does not come back in an epidemic
form as it has happened in some other countries.
Also, following the model of the NMEP, a
specialised military style campaign was launched in
1963 to
eradicate smallpox within three years
13, p. 130
Once again the campaign conspicuously
failed to achieve the result of eradication. Only
recently ( 1973-74 ) yet another campaign has
been launched to eradicate smallpox “ once and for
all ” 15 pp-mass carnpaign to provide BCG
vaccination to cover the entire population of the
country, and to continue to do so periodically, was
the first effort to deal with the problem of tuberculosis
in India as a public health problem 15 pp- 120121.
This programme, unfortunately, also failed to yield
the desired results 21. Special campaigns have also
been launched against leprosy, filariasis, trachoma and
cholera with even more discouraging results15 pp* 61106.
The health service system of the country had
hardly recovered from the consequences of the very
eostly failures of the mass campaigns against malaria,
smallpox, leprosy, filaria and trachoma, when a large
bulk of investment in health was cornered by another
specialised campaign- this time it was against the
-rapidly rising population of the country. The Fourth
Plan investment in family planning was Rs. 3,150m
as against Rs. 4,500m for the rest of the health sector
of the country2’ p- 11. This involved deployment
of an army of 125,000 persons 2- p* 15. All of them
were specially earmarked for doing family planning
work only. Significantly, once again, this programme
was also developed by officers belonging to the
Indian Medical Service—the colonels, with strong
backing from foreign consultants from various
agencies. Predictably, once again, this campaign also
failed to attain the demographic objectives, with
disastrous consequences, both to the programmes for
socioeconomic development as well as to the develop
ment of a sound infrastructure of health services for
the country 2’ pp- 222-224» 17.
Recognising, at long last, the weaknesses of this
campaign approach, recently the Government of India
has veered round the idea of providing an integrated
package of health, family planning and nutrition
services with particular emphasis on the weaker
sections of the omnmity 1S’P- 184 . This package
in turn, is a part of a bigger package of the Minimum
Needs Programmes of the Fifth Five Year Plan
( 1974-1979 ) which is meant to deal with some of
the very urgent social and economic 'needs of the
rural populations of the country 29’
Serve them
Development of a T
Permanent Integrated Health Service
System for Rural Areas :
The Health Survey and Development Committee’ 6.
which was set up by the British Indian Government
in 1943 to draw a blueprint of health services for
the post-war British India, had shown exceptional
vision and courage to make some very bold recommen
dations. These included development of an elaborate
health service system for the country, giving key
importance to preventive aspects with the “ countryside
as the focal point ” 6’ p- 6. To forestall any criticism
of the recommendations on grounds of practicability,
pointing out the achievements in health in the Soviet
Union within a span of 28 years (1913-1941), it
asserted that its recommendations are quite practical,
in fact relatively very modest, provided there was
the will to develop the health services of the
country 61 p* 1o. Unfortunately, however, the leaders
who took over from the British did not show this
will. They had quoted, often out of context, the
recommendations of the Bhore Committee to justify
abolition of the licenciate course and to establish a
very large number of medical colleges with sophisti
cated teaching hospitals in urban areas. They also
invoked the Bhore Committee to justify to setting up
an even more sophisticated All India Institute of
Medical Sciences in New Delhi on the model of the
Johns Hopkins Medical Center of the U.S.A. 5’ p- 322.
A number of other postgraduate centres for medical
education were also set up in due course. It, however,
took them over seven years even to start opening
primary health centres to provide integrated curative
and preventive services to rural populations of the
country ■1. These primary health centres were a
very far cry from what was suggested by the Bhore
Committee; they did not have even a fourth
of
“ the
irreducible
minimum requirements ”
of staff recommended by the Bhore Committee for a
given population (and that too only as a short term
measure) 1 c’p- 1’. Furthermore, it took more than
10 years to cover the rural populations in the country
even with this manifestly rudimentary and grossly
inadequate type of primary health centres.
The entry of the National Malaria Eradication
Programme into the maintenance phase and concurrent
development of an extension approach to family
planning provided a transient impetus to providing
integrated health and family planning services through
multipurpose male and female workers 21. But the
clash of interests of the malaria and the family plan
ning programmes again led to the formation of
unipurpose workers for malaria and family planning 23.
What was even worse, application of very intensive
Learn from them
pressure on various workers of primary health centres
to attain family planning targets led to the neglect of
whatever health services which were earlier being
provided by the PHCs, thus causing a series of further
setbacks to different health programmes 2’ p’40.
Maternal and child health services, malaria and small
pox eradication, environmental sanitation and control
of other communicable diseases, such as tuberculosis,
leprosy and trachoma, are examples of the services
which suffered as a result of preoccupation of health
workers with achieving the prescribed family planning
targets.
Very recently, following the recognition of the
fact that a unipurpose, high pressure military type
campaign approach which does not ensure a concurrent
growth and development of other segments of health
and nutrition services (and, growth and development
in other socioeconomic fields) will not be able to
yield the desired results, as pointed out above, deci
sions have already been taken to integrate malaria,
family planning, maternal and child health, smallpox
and some other programmes and thus provide an
entire package of health, family planning and nutrition
services to the community through male and female
multipurpose health workers 18, 19.
The Indian Systems of Medical Services In India
There are three major indigenous systems of
medicine in India : Ayurveda—the Hindu medical
system; Unani—the Greek system of medicine which
was brought to India from West Asia by the Muslim
rulers of India; and the Siddha system, which can be
considered to be a specialised branch of Ayurveda.
After Independence, these systems were subjected to
two contradictory pulls : their being firmly rooted in
the culture of the people of the country for centuries
and their rich heritage invoked considerable admiration
and even certain degree of emotional attachment from
a large section of the population of the country. And,
at the same time, long neglect of these systems of
medicine led to a very sharp deterioration in the
body of knowledge, in their institutions for training
and research, in their pharmacopia and drug industry
and in their corps of practitioners. Therefore, while
the leaders of independent India built almost the
entire health services on the lines of western system,
they have from the very beginning, shown sympathy
for the Indian systems of medicine and have made
available some grants for conducting research in these
systems, for supporting educational institutions and for
providing some services to the community 23.
REFERENCES :
1. Basu, D. D. (1970) : SHORTER CONSTITUTION
INDIA, Calcutta : S. C. Sirkar, pp. 230-235.
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2.
3.
4.
Banerji, D. (1971) : FAMILY PLANNING IN INDIA :
A CRITIQUE AND A PERSPECTIVE, New Delhi :
People’s Publishing House.
Banerji, D. (1973) : POPULATION PLANNING IN
INDIA : NATIONAL AND FOREIGN PRIORITIES,
INTERNATIONAL JOURNAL OF HEALTH SERVICES,
III : No. 4.
India, Government of. Health Survey and Development
Committee (1946) : REPORT, Volume I, Delhi : Manager
of Publications.
5.
India, Government of. Ministry of Health, Health Survey and
Planning Committee (1961) : REPORT, Volume I, New
Delhi: Ministry of Health.
6. India, Government of. Health Survey and Development
Committee (1946) : REPORT, Volume II, Delhi : Manager
of Publication.
7. Ramalingaswami, P. and Neki, K. (1971) : Students’
reference of Specialities in an Indian Medical College,
BRITISH JOURNAL OF MEDICAL EDUCATION,
V : 204-209.
8. National Institute of Health Administration and Education
(1966) : REPORT AND RECOMMENDATIONS OF THE
CONFERFNCE ON THE TEACHING OF PREVENTIVE
AND SOCIAL MEDICINE IN RELATION TO HEALTH
NEEDS OF THE COUNTRY, New Delhi : National
Institute of Health Administration and Education.
9. India, Government of. Ministry of Health and Family
Planning (1973) : POCKET BOOK OF HEALTH STAT
ISTICS, New Delhi : Central Bureau of Health Intelligence,
Directorate of Health Services.
10.
India, Government of, Ministry of Health, Family Planning
and Urban Development, The Study Group on Hospitals
(1968) : REPORT, New Delhi : Ministry of Health, Family
Planning and Urban Development.
11.
West Bengal, Directorate of Health Services (1971) :
HEALTH ON THE MARCH 1948-1969 : WEST BENGAL,
Calcutta: State Health Intelligence Bureau.
12.
Ramakrishna, S. P. (1960) : An Examination of Resem
blance and Divergence Between War and Malaria Eradi
cation, BULLETIN OF THE NATIONAL SOCIETY OF
INDIA FOR MALARIA AND OTHER MOSQUITO
BORNE DISEASES, 8 : 3-4.
Borkar, G. (1961) : HEALTH IN INDEPENDENT
INDIA, Revised Edition, New Delhi : Ministry of Health.
Banerji, D. (1971) : Tuberculosis : A Problem of Social
Planning in India, NIHAE BULLETIN, 4 : No. L, pp. 9-25.
13.
14.
15.
India, Government of, Ministry of Health and Family
Planning (1973) : MEMORANDUM ON CENTRALLY
SPONSORED AND PURELY CENTRAL SCHEMES
FOR THE FIFTH FIVE YEAR PLANS, New Delhi :
Ministry of Health.
16.
India, Government of, Planning Commission (1972) :
THE FOURTH PLAN :
MID-TERM APPRAISAL,
Volume II, New Delhi : Planning Commission.
17.
Banerji, D. (1972) : Prospects of Controlling Population
Growth in India, ECONOMIC AND POLITICAL
WEEKLY, VII : 2067-2074.
18.
India, Government of, Planning Commission (1973) :
DRAFT FIFTH FIVE YEAR PLAN : 1974-1979, Volume
II, New Delhi : Planning Commission.
6
Dear Friend,
We have received very encouraging responses from
the friends to the January - February issue of MFC
Bulletin. Tejpal Jindal from
Sevagram
writes,
“ being the first issue it was beyond expectation.
What I liked most was that the articles can be either
in English or Hindi. ” Appreciating the editorial he
perticularly emphasises,
“....Seeing the attitude
of young medicos, we are left with no measure but
drastic and revolutionary changes. ” He also suggests
that “ theie must be compulsoiy Rural Area Service
for three years after internship and then only MBBS
degree should be assigned to them. ”
The letter from Shri Bapalal Vaidya, an eminent
authority, in Ayurveda, communicates a sense of
agony “ the people need io be liberated from the
grip of doctors and medicines. But who will do it ? ”
He appreciates the efforts of MFC in this direction.
Refering to the article by D.Banerji, ‘ History of
Health Services in India ’ he points out that Charak
( First century A. D.) and Susruta ( Fourth century
A. D. ) are revisions of earlier works.
Charak
Samhita is based on the discources delivered by
Punarvasu Atreya to his talented disciple Agnivesh
in 6th century B. C. Similarly the Susruta Samhita
is also based on an earlier work, the Buddha Susruta
Tantra dated 6th century B.C.,
Nagarjun, a
Buddhist scholor, later revised the original work. For
further information Gujarati readers may refer to
his book ' Charakno Swadhyay ’ Part I (Oriental
Institute, Vadodara ). He adds, “ Alopathy with its
heavy emphasis on curative medicine almost ignores
Preventive Medicine. The students in India should be
taught about Dincharya and Rutucharya, and other
preventive aspects of Ayurveda. Ayurvedic education
too needs to be changed but unfortunately the
vaidyas are helpless as the management is in the hands
of Indian Medical Council. ”
India, Government of, Planning Commission (1973) :
DRAFT FIFTH FIVE YEAR PLAN : 1974-79, Volume
I, New Delhi : Planning Commission.
20. Dhir, S. L. (1971) : Malaria Eradication Programme and
Integration of Mass Education Campaigns in General
Health Services, THE JOURNAL OF COMMUNICABLE
DISEASES, 3 : 1-12.
21. India, Government of, Ministry of Health, Committee on
Integration of Health Services (1963) : REPORT, New
Delhi : Ministry of Health.
22. India, Government of. Ministry of Health and Family
Planning, Committee on Basic Health Services (1966) :
REPORT, New Delhi : Ministry of Health and Family
Planning.
23. India, Government of, Central Council of Health (1974) :
INDIAN SYSTEMS OF MEDICINE AND HOMOEO
PATHY, Agenda item No. 6, New Delhi Ministry of
Health.
19.
Start with what they know
Book Review
A Rush for - Alternatives
A gradual shift to community oriented health
services is quite obvious from the current literature
on health and an attempt to evolve an alternative
approach is becoming the order of the day. While
the trend is welcome, it has to be analysed with
caution because at times the cry for comprehension
and community either tends to become more of a
slogan rather than a well thought of answer to the
prevailing problems or is intended to contain an
explosive situation as far as possible. Some of the
current publications of the WHO and the UN make
an interesting study in this context. These are :
i. Alternative approaches to meeting basic
health needs of populations in developing
countries, WHO
2. Health by the People, WHO
3.
What Now (The 1975 Dag Hammarskjold
Report)
Of these, the first is a record of the 20th Session
of UNICEF-WHO Joint Committee on health policy.
The second edited by Newell is a review of certain
health plans adopted by different developing countries
and the third a document discussing certain broader
issues of the contemporary world.
The first document which starts with demands of
“ revolutionary changes ” and “ radical reforms ”
quickly takes shelter under the safety of neutrality
and hopes that “ inspite of the magnitude and gravity
of the problem and the widespread poverty, ignorance
and lack of resources, much can be done to improve
the health of the people in the developing world. ”
Newell, however, has taken greater pains to look
into the complexity of the problem. He explores the
inter-relationships between health and total develop
ment of a “ comprehensive approach. ” It is for this
purpose that he receives various experiments in the
field of health which were accompanied by a broader
developmental process (the degree and extent of which
varied in each case). The common feature of these
experiments which impressed him most was the wider
goal which most of them adopted. Total development
is their objective and in the process of achieving it,
communities found means and ways of providing
health care to people ”. Newell finds this shift from
achievement of health as an end in itself, to its being
a part of a process of change, very welcome. However,
he does not go into the problems relating development
in these experiments and prefers to end up by saying,
“ there are many roads to success. ” While both
Build upon what they have
Newell as well as the participants of the 20th session
of the WHO join hands in applauding the experi
ments, Newell’s retreat is much sadder.
This is because, the participants of the 20th session
do not even make an effort to look into the issues
of social and political systems and their relevance to
health, while Newell after having recognised the
importance of national will and effort ( which leads
to redistribution of resources) in bringing about
large scale overall changes over shorter periods of
time, tends to treat all the three categories of experi
ments with equal enthusiasm and thus obscures the
relevance of a variable he himself emphasised. He
thereby not only undermines the relative importance
of “ wider development ” essential for better health
of the people (which cannot be optimum in a
framework where health services alone are made the
target for improvement like in Iran ) but also ignores
the fact that intensive efforts of comprehensive nature
conducted by highly dedicated people even if they
are consistant with national goals (like India and
Indochina), may not necessarily be reproducible at
the national level. This is not only because of the
highly atypical inputs but also because of the fact
that these experiments are conducted within a given
socioeconomic system whose premises remain untouched.
The moment that becomes a possibility the continuance
of the experiment itself would be threatened. He also
does not take note of the fact that time is an important
factor which varies widely in all the three categories.
All this is not to deny the possibility of “ many roads
to success ” but to point out that one has to consider
the feasibility as well as the limitations of these various
paths.
As far as one agrees in principle with the concept
of development which means “ satisfaction of needs
the poor who constitutes the worlds majority, at the
same time, development to ensure the humanisation
of man by the satisfaction of his needs for expression,
creativity, conviviality and for deciding his own
destiny, ” there is no reason why health workers may
not spell out the kind of societal framework which
makes this objective attainable. Once that is done any
of the “ many roads ” may be taken depending upon
the reality of the situation and the preferences of the
people. By saying therefore, that “ the forces that
bring about political change are beyond the scope of
this discussion ”, Newell cannot get away from the
responsibility of emphasising the need for such a change.
A counter-arguement to this stand is lllich’s proposi
tion that it is only through a better understanding of
these forces and their influence on health that we can
make health services one of the instruments for change.
7
Another fact that Newell does not realise is, that rejec
tion of political systems of those countries which have
succeeded in bringing about major changes in their
economic and social base, should not necessarily mean
automatic acceptance of the constraints of other
political systems. In other words, it is not simply a
question of rural development being possible “ if
one gees about it in an acceptable way ”, but of an
acceptable political system for rural and overall
development. It is because of this contradiction that
except China, Cuba and Tanzania (to some extent)
none of the other quoted experiments have been able
limit either the expenditure on proportionately smaller
urban populations or the development of two unequal
types of health services within these countries. It is
in this respect that the 3rd document (the Dag
Hammarskjold report ) stands out distinctly both in
its lucid analysis as well as its alternative (however,
idealistic it might be) to the existing political, social
and economic balances.
as they are now organised but rather on new ways
of identifying basic health needs and of providing
simple health measures ” both groups of evaluators
gloss over this inadequacy of the project reports. In
this respect the most that we get is the information
that in Cuba and Venezuela good care was taken to
make use of epidemiological data while formulating
health care programmes and periodic review were
made to fix the quality and norms of care but there
is no mention of any of the details of these processes.
This defeats the purpose for which the whole exercise
was meant that is, of evolving an optimum health
care delivery system within various kinds of develop
mental strategies, formulated in different political
settings. One, therefore, cannot get away from the
responsibility just by saying that “ there appears to
be no good reason why the world should wait for
the answers to be prettily packaged and persecuted,”.
This may be an impatient optimist’s view but is
certainly not scientific.
The attempt of the first two documents to look
for alternatives also suffers from certain conceptual,
methodological and analytical weaknesses. The basic
confusion that <creeps into
•
. concept of 44 primary
the
health care ” is due to a lack of distinction between
“ Basic Health Needs ” and “ simplified health services. ” The result is a premature applause for the
later and conclusions like “ simple primary health
care works ”, without actually demonstrating their
effectiveness by keeping the non-medical developmental
inputs constant (like availability of food, sanitation
and increased productivity). This is true for all
projects except for Iran where although the project
has no inbuilt non health inputs (excluding water
and sanitation) but due to the sudden increase in
Petrodollars there has been some trickle down effect
in the economy resulting in some degree of economic
relief in the rural areas. Again, this is not to in any
way discredit the efforts to make health services simple
and widely available but to point out that their
impact is intimately related to the state of availability
of other basic facilities to people and that they have
to be optimised within the total developmental progran
. A point which again the Dag Hammarskjold
report very clearly makes.
The case studies are further handicapped by the
absence of any data pertaining to the indices which
might have helped the reader in assessing the impact
of these programmes.
This brings as to the methodological question of
what processes these various projects adopted to arrive
at the chosen health care delivery system and was the
system optimised ? Unfortunately none of the case
studies elaborate on this issue, Inspite of impressing
the need not to further elaborate on “ health services
Another problem that has not been pointed out
by the evaluators is the fact that although most
projects have attempted to develop a grass-root
worker and some kind of infrastructure to provide
curative and preventive services, most of them primarily
talk about curative aspects only. While it is true
that to begin any kind of total health care programme
curative services are essential, it does not exclude the
possibility of an interwoven on running programme
of public health, Such an approach is not apparent
at least in the on going programmes in Niger, Nigeria,
Gautemala and even Tanzania. While they all men
tion communicable disease prevention, immunisation
and MCH services, the extent of coverage and
continuity of these programmes is not clear.
One, therefore, wonders as to why these projects
have been picked up as case studies, as they neither
demonstrate optimum resources utilisation nor are
they examples of proven effective health care systems.
If the idea was to emphasise the importance of total
development or variety in health services on hope in
the future, then health services of any country could
have made the point (even by their failure ). However,
if the purpose was to develop an optimum alternative,
then we have not picked up all the right examples
nor gathered relevant information about them.
--IMRANA QADEER (J.N.U. New Delhi)
Editorial Committee : imrana qadeer, prakash bombatkar, satish tibrewala, kamala jayarao, mira sadgopal, abhaya bang, george
isaac, sathi devi, bhoomi kumar j., suhas jaju, lalitkhanra, ashvin patel (Editor)
# title design : purna, nid, ahmedabad
Edited and Published by - Ashvin J. Patel for Medico Friend Circle from 21 Nirman Society, Vadodara-390005,
and Printed by him at Yagna Mudrika, Vadodara-39001.
Souvenir for private circulation only
NEED FOR SETS OF CONCEPTS IN HEALTH SERVICES RESEARCH
Health problems and health status
A.
Wb<t is a case? An episode of
illness? A health behaviour event?
What is meant by the ’’general level D.
of health” of individuals and popu
lations?
Does ’’health status” include sets
of concepts concerning information
and knowledge of health, illness,
and of courses of action?
Does the ’’general level of health”
include interference with daily
activities due to health problems?
What are the relationships between
the foregoing sets of concepts?
Do the above sets of concepts pro
vide an adequate base for concepts
to indicate needs for health care
and do they contribute to the need
for descriptions of lay and pro
fessional expectations of care?
1.
2.
3.
4.
5.
6.
Use of medical services
1.
2.
3.
4.
5.
6.
The set of concepts concerning the
use of health services is multi
dimensional.
Points of entry into the health
care system and flow through the
system need to be conceptualised.
Sets of concepts for describing the
content of the transactions between
health personnel and lay popula
tions may be aided by distinguish
ing between health maintaining,
illness defining, and sick role
behaviour.
Both health personnel and the con
sumers of health care react at
cognitive, instrumental, and
affective levels.
Lay and professional perceptions of
some key attributes of health care
interactions may be significant for E.
health planning and manpower studies.
There is need for concepts which
connect the five dimensions to
utilization of health services
given above.
Outcomes of episodes of illness and
of health events
C.
io
2.
Particular and current emphases are
on concepts of the presence or
absence of disease, degree of inter
ference with daily activities and
disability, extent of discomfort or
distress, and the degree of satis
faction or dissatisfaction with the
outcome of illness episodes and
health behaviour events.
Current emphases need to have sets
of concepts which incorporate lay
and professional medical assess
ments, particularly changes in the
clinical signs of illness and
sickness.
Finally, there is need for con
cepts to denote changes in levels
of health knowledge and information.
3.
Other personal, family and group
attributes
Concepts of various components of
social structure, both micro- and
macro-cosmically considered, are
important dimensions to the behav
iour of both lay populations and
health personnel.
2« All papers stress the need for con
cepts to describe the components of
cultural systems.
3. Concepts for considering socializa
tion processes are discussed by
several authors. Past experience
with health problems and health
maintaining behaviour may be con
sidered sochlization processes.
4. The loci of decision-making pro
cesses involve responses to symp
toms of illness and choices from
among alternative sub-systems of
health care.
5. The need for concepts to describe
communication processes and styles
is implicit in all papers.
6. Sets of concepts to denote economic
and demographic information apply
to both lay populations and the
providers of health care.
7. To what extent do the groups of
concepts discussed thus far - epi
sodes of illness and other health
events, the use of health services,
outcome and the preceding attributes
— contribute to the development of
sets of concepts like vulnerability,
susceptibility, predisposisions, and
risk factors?
1.
Environmental influences
1.
2.
34.
5.
6.
7»
Concepts which denote and describe
the system of health and medical
care.
General social characteristics, par
ticularly social and cultural change
in the present era.
Concepts are needed to describe the
demographic structure of populations
and of families.
Sets of concepts are needed to
denote the nature and extent of
environmental hazards to health.
Attributes of the economy need
standardized sets of concepts.
Concepts of geographic phenomena
are implicit in all of the papers,
but the need for such concepts must
be made explicit.
To what extent may environmental
attributes, and the others outlined
above, be considered enabling or
hindering factors in the achieve
ment of health goals?
*
COrv) H
ad
C<owW"”"1''
' PAPER.I.
4
oat*0
HEALTH SERVICES IN INDIA:
An Introspection
- Ahhay Bang
orking paper presented for the Myh All India Conferer-.
of Medico Friend Circle,
□.kxuio.u
j- au
at Ramanatakara,Kerala
on
December 29th,30th and 31st,1977)
All is not well with the medical profession and health
services, Ivan Illich in his book’Medifal Nemesis’ questions
the contribution of the medical profession and practice to
the health of the society.
What stand should we take? Should we continue to be
^Jef-hypnotised and fully contented about our profession
harping on its ‘Noble’ role of service to the humanity?
Or should we do some honest and critical introspection
about our real situation and our utility to the society? Such
an introspection may endanger our pride and content about our
profession. Are we prepared to run that risk?
Criteria for Judgement:
A.
8 ‘
.
What should be the criteria for judging the pfrfoFinance of medical profession?
- Is the art and science of medicine an absolute
- end in itself?
— Or it should be looked at as an activity delegated
to a profession by the society for the service
of the society?
This question can probably be better answered if we glance
at where from the resources for flouiishing of this profession
comei) Educational privilege we enjoy in becoming a doctor
How many people get education?
- Only 30% are litrate
How many go to University?
- Only 3-2% of the population.
How many get a chance to acquire the most coveted
education of today - The Medical Education
Only 0.02% of the population.
ii) Investment by the society in making a doctor:
Estimated to be about 1 lac Rs.
iii) Expenditure by the society for running the medical
college^hospitals and research centres so as to
provide working conditions to the doctors.
iv) Socio-economic status of the doctors in the society
and the privileges we enjoy(Ref.No.1).
contd...2/-
contd.,...2/It should be obvious that we,by way of our education and
profession heavily draw resources from the society. In view
of this social obligation, what should be the criteria to judge
our performance?
- Utility to the society
- Or utility to further our personal as professional
interests?
Targets for health Services:
Wfaat targets the health services in India should have
achieved in the past 30 years of independence?
B.
1) The constitution of India, in its directive principles,
says, "The state shall regard the raising of the level of
nutrition and standard of living of its people and the imprcrvement of public health as among its primary duties".
2) ’i'he first National Health Conference in China(l9?0) set
an exemplary target in the following words" How far can a mother on foot carry her sick child in
the heat of summer? That is the greatest distance the nearest
health worker should be"
3) The Bhore committee in 19^6 recommended following
guidelines for planning and organls ing the health services in
India- Preventive health work should be given more importance
- Rapid extension of health services in rural areas.
- Lack of ability to pay by an individual
should not become an obstacle in getting him tne
required medical care.
- A net work of primary health centres be established.
C.
Performance Judged*
Judged against these targets, trhat is the situation today?
1) Have the standards of Nutrition and Public Health been
raised?
- Average Calory intake has gone down. Today it is
2000 calories/day which is far less than required,
specially for working class,for whom the calory
retirements are 3000 and 3900 for female and male
respectively.
- Protein-Calory malnutrition,Vitamin.A.deficiency
and Iron deficiency anaemia are still rampent m India.
- Tuberculosis,Leprosy,Filariasis,Malaria are still
let loose on the masses.
2) Was preventive work given more importance?
- It is estimated that 60-70% of the health problems
in India could be solved if safe water supply end
contd,.o,3/"
1
contd....3/system .of excreta disposal could be provided to all the people
Inspite of this,only '+% of the rural population gets piped
water supply; 1+0% of the urban population and almost zero
percent of the rural population is provided with excreta
disposal system.
-Expenditure, on curative services is 3 times that on the
preventive services,
- In health services the preventive work is always neglected
as it is dull,difficult and not immediately rewarding.
3. Was rapid extension of health services in rural area done?
- Even after accepting the recommendations of the
Shore Committee, it took 7 years to start the first
P.H.C.
- There was no PHO in 38 blocks in Maharashtra till
- According to WHO Survey(l9?) rural India where 80% of
the population lives and which contributes 75% to.the
national production receives only 25% share of the health
services»
•
.. ....
-90% of the hospital beds are located in the cities and
the towns, far from the rural population,which is more
exposed to and more vulnerable to the pathogenic agents
and hence requires health services more acutely.
- Few years ago the’health Minister admitted in the
Parliament that there were rural areas where there was
no doctor within the distance of 50 miles(what is the
distance the Mother on foot with the sick child can-—
walk?)and for more than 1 lac of population,(Mudliar
Committee recommended 1 doctor for 3500 population)
h-. Was the PHC net work, which was to form the sheet anchor
of rural health services, done full justice?
- Shore committee recommended 1 PHC 10 to 20 thousand
population,with each PHC having 3 doctors,20 nurses
31 other assistants and a 75 bedded hospital.
r At present there is one PHC for 1 lac of population
with two doctors,8 ANM and 8 to 10 ill cared beds
at each PHC.
- Very meagre budget for drugs and petrol. (Rs.
(Rs. 2500/and Rs.300/- per year per PHC in UP) with about 100
villages to be served.
- Gross apathy,inefficiency and insincerity in the staf.C
working there.
Is money not the most important determinant to decide'
the standard of medical care a needy person will receive
in our country?
a) Govt, health services are very meagre and far away from
the needy persons, hence usually inaccessible.
- The budget for drugs for PHC is 2.5 to 10 paise/perso’-z
year i.e.grossly inadequate.
- Even out of this quota corruption snatches away a substancial portion.
contd...U/-
)
I
contd
..V-
Can the poor people in villages get the required medical
care fronyfchis system?
b) What about private sector? -60% of the total doctors
in India work in private sector.'Sutf- Where do they usually settle,urban on rural area?
« Hqw much malpractice do they do?
w Can the poorest man afford their fees and the cost of
the drugs?
- Which class of people can afford to get admitted and
treated in the private hospitals?
If this is the state of health services 30 years after
the indepcndance, how will you rate this performance against the
targets expected to be achieved?
D. Relevance of present system of health seryj^es in India
In view of this miserable performancet a critical exam!-- ■
nation and radical rethinking is needed about our health services
system. Are cur Medical education^ research and health care
system relevant economically,socially and culturally to the
Indian situation and needs? Or they are blind aping of the medical
services in the developed Western countries,suitable only for
the requirements of the upper class in India?
I) Medical Education.
i) Aim* what should be the aim of the medical education?
According to the WHO committee for South East Asia”,
the purpose of the medical education is not to produce
Noble Prize winn rs but to provide doctors for health
services who will meet the health needs of the country
in which and for which they are trained.”1
ii) In this
light,how much relevant our education is?
a) Conditions we are trained in and trained for
-Conditions we actually have’to work in and work for
b) What emphasis is given during our education? Moro
time is spent on cardiology or on diarrhoea &
dehydration?
Cardiological diseases are responsible for 2.% of deaths
diseases for 55% of the deaths.
in India, <while
--- communicable
----Cardio-vascular disorders are predominent in which
class? In which countries- developed or undeveloped!
Has this something to do with excess of imprtance
given to CVS diseases?
contd....5/-
contd... .5/c)
d)
What type of diagnostic techniques and the^methods
of management we learn in our textbooks? Are these
India,
available and practicable every where in I
’^ia, more
at ions we have made/L
so in the rural area? What adopt
adoptations
. in our medical education to make it suitable for the
working conditio ns and needs of rural India.
Which subject is given more importance? Medicine or
Preventive
■ y h and Social Medicine? What is the condition
of the
the”PSM
'PSM departments
denartments in our i..
medical colleges.
- The attitude of the students •
•” The attitude of the c^^^cians
of the stafFof-'the PSM dept, itself.
- The attitude c_
There was no department of PSM in the Post-graduate Institute
,Chandigarh even 1$ years after its inception.
Is all this consistant with the realities and the needs
of the society?(Ref.No.2),
lii) Have medical institutions.beai given undue importance
in our health planning as compared to our need for the type
of health man power?
- After independance the number of medical colleges__giew
from a handful to.103, ■ ThG^e are 13 medical colleges in
Maharashtra(3 more than the recommended), Delhi has U as
against recommended quota of one.
- Number of doctors has inefeased from 17,6^9 to 137,930
- About 3/M- of the health budget .of the states is spent
on these white elephants,called medical colleges.
- A big hue and cry was recently raised in Maharashtra
' for increasing the seats in the Medical Collges. To
accommodate these new admissions,the Government has
made additional allocation of crores, of rupees.
a) What for and whom for these new doctors?
b) Where these doctors are likely to settle.after their
community-financed( 1 lac Rs.each) education is finished.
c) Whether few highly trained doctors at Etch a colossal
cost is the need of the society?
Or we require an army of basic health workers who
are trained at low cost, who can be available to that
'Mother on foot', and who can manage Ecatine health problems
effectively?
iv) If the choice is between doctor and the auxi.l larya) A doctor:
- Usually comes from which class?
- Psychologically attached to which culture*
urban or rural?
- Trained to work in which place:
hospital or rural dispensary?
contd.... 6/-
cont(if... 6/So when such a doctor is given the choice,what does he
prefer?
w Migrating to USA or giving to rural area?
• Can he identify with -rural culture and people?
w Is he effective in working in a rural dispensary? Arc
his skills fully utilised?
In summary, is today’s doctor fit to work in the rural
setting?
b) Auxilia ryt
1) A villager expects 3 qualities from his doctor:
availability; friendliness and skills
- Q^t of these 3, on how many points auxiliary scores
over a doctor?
.-■j
•a
2) Ape the skills of an auxiliary adequate?
n An Auxiliary ca^n treat 90% of children’s sicknesses11Rural health Research Centre,Narangwal
11 I am convinced that in siny field of health technology,
it has been shown that with only 2«3% of conventional
medical technology, we could arrive at 90% of necessary
quality care",
« Mahler Halfman (Director ♦ General,WH(£
3) 31 countries are using auxiliaries for providing
primary medical carej
Inspite of thes£ facts, the present ratio of doctor to
Nurse in India is IO;1)- which results in wastage of extrevaganV
skills of doctor at the cost of .paucity of auxil aries^In
Sweeden, the ratio is 1:3,which is an ideal one*£
v) On this background, what do you think about the Raj
Narayan Scheme of training of health workers?
- What arc its good points?
- What ate its drawbacks?
1
2)
Rdscarch:
- VJhat should bo our research priorities?
- Communicable diseases
- Nutrition
- Degenerrative diseases
- Metabolic disorders
- Fertility and its control
- Cardio-vascular diseases
- On which topics usually our academicians(at the expenses
of the society) concentrate and publish their research?
- What this disparity?
- Craving to get personal recognition in Western
journals.
contd...?/-
contd*. .7/**
-Cultural slavery of the West(Ref•No<3)
-iinawareness of the needs of India
-Lack of feeling of responsibility and accounta
bility to the society.
Gunnar Myrdal Comments in the challege of world1 Poverty4'....” ..The young intellectuals in India and in most of the
non -communist under developed world have been so conditioned by
the rigid elite and class structure in which they have been brought
up that they do not feel that deep indentification with the poor
in their nation.... They do not feel it when in some countries
they are radically indoctrinated. This is merely one example
of the destructive influence of the fortified class society
inherited from the clonial era.”
- In China all University teachers have to spend one year
in every three years in the rupal area.such measure solve
the problem of inory tower research workers?
3) Health Cape Service:
The present set up of health care services is.based on
wHospitalsfPHC and private practitioners.
i) Hospitals:
With specialised,well equipped services
- Capital intensive or labour intensive?'
- Curative or preventive in nature?
- Where situated?
- How much available and accessible, to all people?
- Can we provide this type and standard of medical
care for the whole country?
- If not,why this disparity that big hospitals.for
cities and(with result) no services in the villages?
Is this pattern relevant to our needs?
Jolley and King estimated the cost of treatment
per illness at various levels of services as follows
Health Centre
...
b- Shillings
it
Rist.Hospital
....
8U
t!
Regional Hospital ...
1?0
I!
National Hospital ...
370
•Due to this raised cost of medical care at hospital,we are
able to reach fewer and fewer people and inturn deprive more and
more people. This is especially true about socio-economically poor
people (60%) of the population). This raises a question- For whom
are we responsible? Ape we responsible to those who do not reach
or can not rea-ch the hospitals? Those who are in grea-test need
can not reach the hospitals.
contd....8/-
contd...8/-
ii) P.H.C. Its condition we have already examined.
-Does this miserable condition of PHC services(less
than
of the irreducible minmum of Shore Committee) reflect
the level of concern of policy makers and executives for the
health of rural poors?
- Can the superstructure of hospitals be effectively
and economically utilised without efficient and widespread
infrastructure of pHCj1
Then where should we first concentrate our limited
resources?
ill) General Practitioners:
- Mai distribution: rural- urban
- Cost of treatment
- Attitudes and aims of practice and malpractice.—~
iv) what approach we need?
a) Alm of the health care should be:
- To make people more and more dependent on medical,.Aid.
• To prevent occurrence of the disease and to educate
th be self reliant?
b) Then what approach do we need on the .following ^oinus?
i) Beneficiaries of the care
ii) Priorities of the health programmes
Pattern of health care delivery system and
priorities.
iv) Type of manpower
v) Utilisation of non allopathy practitioners?
(There are 1,09,50'+ Homeopathy,Ik-,000 Siddha,
18,000 Unani,1,pO,000/- trained Ayurvedic.and
2,50,000 traditional practitioners in India..
On this manpower be utilised after some training"
An effort was done by the Govt. of India to use
them(Peasant’s doctor) by authorising their practice,
What happened to it? What was the reaction of
IMA ?- Why?
vi) Drug industry.
E)
Root causes of irrelevance of present Health ScryicesJ
Following incidences should enlighten us:
1) Then Prime Minister Mrs.Thdira Gandhi said that India
needed such health services which would be cheap and would reach
the' rural masses. This she said while inaugurating Jaslok
Hospital in Bombay
Why this disparity
between speech and deed?
contd...9/"
V;-'
;y :
7 ' ' I'
• t (••■i.i < ■
' I
. ,
uth
.
.... fcoad
. 12 - t-uu 001
Gor>) H
I
GENERAL APPH0ACH TO EURAL CO? .OJNITY HEALTH gHVICES.
Fundamentally. the health services hive to be viewed in the
context of overall integrated development of the villages# Health
services cannot be fully successful if ihey are pursued in isolation
from the general development activities of the area#
The community health services must be area basedand population
based — providing the total spectrum of health services to the toxal
populace living in a defined geographic area# Primary health care
must be available at the doorstep of the receipients#
1. Area Coverage —
Re/^Lonalization:
we must accept responsibilities to provide health coverage
to the population of a defined area.
iiClecVlqn fLrite.ri.i_of th£ Area^.
a)
Necd-
Poverty and illiteracy
hifh incidence of diseases
non-availability of health services.
B) Suitability;
— The area should not be too far nor should the area
/Ae
be too near to Patna-- then the people will be visiting
CrVy
for their health needs.
Assurance by the community for full cooperation and
help.
How ?
for example:
i)
If there is an already existing useful organisation
that can provide us useful assistance#
ii)
If the village is well united and there is an effective
panchayat#
iii)
If the village has,or is willing to immediately start,
a ^ill5
Health Committee, which could help us in
several ways, acting as ar effective linke between the
health workers and the villagers#Such a health committ(
should preferably be considered a specialized organ of
the panch-ayat unless the punchayat is divided and
ineffective. Then the Village Tealth Committee can be
an independent institution.But it must enjoy the
confidence of the entire village population.
- 2
iv) If the villagers are willing to contribute their share
by:
1. Agreeing to pay a small Insurance charge
2. A greeting to do Shramdan for some health projects
3. Agreeing to contribute volunteers that will help
run the health programme.
v)
If some data is already available about that area due to
previous or on-going survey etc .either in connection with a
health proframine or as a part of general development activities.
• Total PoTulation Coverage:
The whole po ulation must bo covered.
Priorities:
The weak and tlie vulnerable:
children below 6
Expectant mothers
N u rsin g moth e rs
Promotion of health and prevention of disease.
I'utritionfSani'tation,Immunisations '■ Health Education
Adequate simple records.
3. "Health Insurance"
Advantages:
Every body pays.
There may be a graded scale depending upon the
economic status.
Greater inter'st taken by the community
Greater community participation
People fefil they own the program ie—and it is their
(as indeed it always should be).
People who pay can also ask for good services, and
who can complain if the services are not good.
Keeping accounts develops the idea of account ability
People do not value the treatment that is given free
They may even throw away expensive drugs, th ink in.
them worthless.
Getting things free is not a good habit.lt should
be discouraged.
Some people consider it ethically wrong to give or
take things free.
There is no such thing as YREE.t^±±c~h-■ os*if the
villagers are not paying for it,somebody else must
be payiiig for it.
....3/-
• 5 4. She National Context and Ccaristoxinte:
Ours is a poor country.
Our health services should be affordable on a countrywide basis,
perhaps guiding upto a few rupees per head per year.
It is no use creating an IDEAp or achieving ’’excellence”, wh ich
cannot be copied on a large scale.
We must keep in mind the replicability of our health services. We
should be able to demonstrate a pattern of health care which is
practicable and effective- not after 50 years,but for the next
5 year plan.
Thus oui1 efforts should hove national relevance. V/e have wasted
our opportunity if our health services and experience cannot be multiplied
and does not have any relevance for the creation of effective health
services on a country-wide basis.
5.
Coordination v/itli tie titate health or^isation.
Health is a State subject.
V.;e fiiculd avoid dual control or parallel and competing health
services. -;e should have a clear understanding with the otate health
linistry and ihe -district Chief Medical Officer. V/e should clearly define
our respective roles and establish clear channels of connunications and
cooperation.
Broadly, our plan for co^ifunity health servi ccs should fiaax
follow the state pattern. V'c can fill in the lacunae and strengthen
weak links,but we should not drastically after the overall health plan
or health strategy. Otherwise we again face the risk of wasting our
opportunity ind losing all relevance.
6.
Utilisation., of Existing co ?unity Resources:
They include:
/Tou- J
mxyco
Indigenous and homeopathic practitioners
Crdimiy simple home remedies
The common lore and grandmas recipes^Yoga.
Health practices of our people, such as personal
cleanliness,boiling of miIk,breastfeeding of
children self reliance etc.
Local educated young men and wo men, inc lading
teachers, post -man etc that can be roped in for
ricUB typ®8
comes to vill ;/es.
atrophy of local leadershi > and initiative
and fostering an attitude of dependance and
passive acceptance.We must guard against ihe
tendancy to pull poeple up by their ears,instea
of encouraging them to pull themselves up by
their boots—traps.V/e should resist all well
intentioned effort to spoonfeed the people.
- 4 Instead, we should encourage local leadership, local
initiative and self reliance. At a practical level, we
should select suitable educated young men and women from
the villages themselves, and train them as health workers.
We ahouId also involve the community in all health work,
rifht from the stage of planning onwards, fetaxotea
9* Community IHirtici .x.tion:
A community should consider the health services as their
own. Community participation is the sine qua non of any
successful community programme. This is one reason why the
community must pay for its health services partly,if not
wholly.
The connunity must be involved in all stages of the
community health programme, inc lading decision making.
Planning
Finan c ia 1 contr ibut io ns
Selection of workers from the community
Evaluation of their woik.
Village Heal tit Commit tees can play a very useful role
here, as already mentioned.
10* 3~peci-.il ;<ole of Health -ducation
Health education is essential in a democratic set-up in
order to elicit the willinr and enlightened cooperation of the people
It increases peoples competence to look after their own
health,thus fostering self-reliance.
It helps people take greater interest in their health
services.
It helps people identify incompetent workers or incorrect
measures*
Everybody is interested in tic working of his/her body 9
and in health. They will pay attention if healtheducatioxi is
imagine lively carried out, using for example puppet shows, one act
plays,practical demonstrations ,mobile exhibitions, etc.XDBS
- 5 The following topics should be covered:
First-aid
Simple nursing
Body knowledge
Yoga
Personal hygiene
Balanced diet.
Some simple preventive measures etc.
11. Phasing and Pilot projects:
We should start with a small area or start with only a
few services or both.
10.
We should expand and multiply health scexvss
we gain more:
insight
experien ce
confidence
acceptability
efficiency.
Essential Steps:
services as
•?7
To Implement the Community Health Programme.
Objective: To create comprehensive integrated community health
services for the total population of defined rural areas, with emphasi
on vulnerable groups and on prevention.
Such a sei’vice should be made available on a regional basis,
alongwith effective referral facilities.
Sm-iary of Steps:
1. a .managing committee of-overal 1- Jayaprabha--H
it al, Research
Centre and Community Health Programme should be. established •
2. Constituting a "Planning and Implementation” Committee for the
Community Health programme.
3. Selection of suitable area or areas of work.Selection criteria
already mentioned in the general approach.
- 6 4.
To study the area(s) to define its problems and assets.
purveys;
‘This will involve planning and conduction of surveys
covering the following variables:
Demographic
bocio-econonaic
Health - Existing proble m
- Existing facilities.
5* Planning:
Preparation of preliminary plan
Biscussions
i<ead justnents
Finalization of the broad plan.
6. Iaplementation:
Selection and training of workers
Building xnd furnishing of hospitals .health centres ei
Phased beginning of health services.
1
7. fiecords— should receive special attention.
8. Evaluaticai of Community health services — both concurrent and
terminal. This should help better planning:
Plannin g
Programing
Administration
Evaluation.
1
Cell I
f
G O r-'O H S * G
GUIDELINES FOR DEVELOPING
ALTERNATIVE MODELS FOR
DELIVERY OF HEALTH CARE
The Author Kamala Gopal Rao is Professor and Head of the Department of Social
Sciences, National Institute of Health Administration and Education,
E-16, Greater Kailash, New Delhi.
In India, even before the attainment of indepe
ndence the government was concerned with the
problem of providing adequate health services to
its population. In order to survey health condi
tions and health organizations and to make recom
mendations for future developments of health servic
ie Health Survey and Development Commi
ttee (Bhore Committee) was set up in British India
in the year 1943. The recommendations of this com
mittee contained in their report of 1946, provided
the blueprint for the development and implemen
tation of health services in post-independent India.
Of the several aspects of health services organi
zation that this Committee deliberated upon, the
more important ones were the following:
1.
2.
The need to cut down the preventable
morbidity which was estimated by the
Committee to be about 50 percent.
The need to correct the imbalances bet
ween the rural and urban areas in terms
of health facilities and health manpower.
3.
The need to provide medical relief and
preventive care to the vast rural popula
tion of the country.
4.
The need to recognise the importance of
social, cultural and environmental factors
in the preservation of health.
5.
The need to develop a philosophy of self
help and cooperative endeavour among
people to improve their own health and
maintain a healthful environment through
widespread health education and increase
in general education.
The need to shift the emphasis of the hea
lth services from a predominantly curative
approach to one with sufficient emphasis
on prevention and promotion.
6.
7.
8.
9.
The need to review the problem of health
in the broader perspective of development
and its social and economic correlates.
The need to provide adequate health pro
tection to all, covering both its curative
and preventive aspects irrespective of their
ability to pay for it.
The importance of social factors such as
unemployment, poverty and social customs
like purdah and early marriage in ill
health.
Considering the fact that it is over 31 years
since the Bhore Committee submitted its^report
and that India attained independence from
colonial rule over 20 years ago, the present deve
lopment of health services obviously is very inade
quate and insufficient, both in terms of quality
and quantity. A somewhat over-simplistic view
of the development of health services tends to look
upon it in a fragmented fashion either in terms of
increasing the number of doctors and the conco
mitant increase in the number of medical colleges
or in terms of increase in the number of hospitals
and dispensaries. The more basic problem and
challenge in providing the health services to the
growing population of India in relation to the felt
need of different populations and sub-cultural
groups within the country has not received suffici
ent attention. Even now, despite sufficient incre
ase in the health budget in the different Five Year
plans there are vast areas in the country where
even the most rudimentary form of health care is
not available. Any plan to provide health care to
Indian communities has to reckon with a few
basic realities of Indian social life. Prominent
among these are the large number of people who
are extremely poor and are described as below the
poverty line (their numbers are estimated to be 40
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GUIDELINES FOR DEVELOPING ALTERNATIVE MODELS
per cent of the population), progressively decreas primarily aims at curative rather than preventive
ing male female ratio as revealed through the medicine. This model is adequate for western
decennial census primarily because of hazards of countries where increased standards of living, high
maternity faced by Indian women (932 women for er literacy, nutrtion and sanitation have resultedin
1000 men), an exaggeratedly high infant and child decreased mortality and morbidity rates and there
mortality; the wide range of preventible sickness fore the total thrust of the health care delivery
to which people succumb; vast illiteracy, especially system is on providing specialised services to in
of females; (even in 1971 census female literacy was dividuals rather than extending general medical
only 21 per cent and rural female literacy was only care and comprehensive health care to communities.
15 per cent) relative neglect of girls and women The Western system, requires an expensive and exte
The National Committee on status of women has nsive medical education system sophisticated equip
quoted figures to show that women use health ment and literate population with some sophistica
services less than men, despite
sickness); tion about disease and some faith in the medical
presence of
vulnerable groups
who need profession. The only modification that develop
particular attention in the health organisations ing countries have done so far while adopting the
-women
in child-bearing years and children western models has been the inclusion of Health
Mow five years; the peculiar age-pyramid Assistants with a little training who essentially act
.h 42 per cent of the population below 14 years; as doctor-substitutes while most of the rural peo
traditional and culturally rooted beliefs on etio ple still depend heavily upon indigenous healers.
logy, spread and cure of diseases; existence of and Even the Shore committee, while outlining the
belief in traditional healers, folk medicine and duties of the primary unit staff suggested that
indigenous medical practitioners; nearly SOpercent Health Assistants should perform both curative
of Indian population residing in villages often in and preventive duties of an elementary nature
remote villages with poor or no communications under the directions of a qualified medical officer.
and other modernising forces. A subtle qualitative The spirit of these recommendations - specifically
dimension is the unwillingness of the urban trai the role of the women Health Assistants in doing
ned doctors to serve in rural areas and the un domiciliary visits to perform curative and preven
willingness of the rural folk to use the existing tive tasks-has not been reflected in the develop
primary health centres (PHCS) and sub-centres. ment of health services in India since the submis
While some have placed the blame on the attitudes sion of Bhore Committee report. At the time of
of health personnel, others have placed the blame Bhore Committee report there were 47,500 doctors,
on the faith of rural folk in traditional indigen while according to recent estimate, there will be
ous medicines. It is, however, true that the rural 1,66,100 doctors in 1978-79. Ramaiah and Bhanfolk, the poor and urban slums have relatively dari state that of these 11,000 allopathic doctors
little access to health services. Paradoxically eno- will be surplus. It is worth noting that the incre
’h, these are the very people who are in need of ase in number of medical colleges, doctors and hos
uealth care.
pitals and dispensaries during the last 30 years has
not resulted insignificant improvements in the health
In the light of these social, cultural, economic status of the Indian population. Partly, thissituation
and demographic realities, the existing system of is due to the fact that health facilities are not the
health care delivery is not relevant for the country only things needed to keep people healthy. Social,
with its vast and varied health problems. The economic and developmental factors affect health
apparent expansion of medical colleges, training status. But no efforts have been made so far to
institutions for other categories of health person make health planning a part of national planning.
nel and number of hospitals and dispensaries with Consequently no action has been taken to integrate
increasing emphasis on super-specialities limit the the medical system with the goals of economic
use of the health care system to the urban elite development. This has been often referred to as
only. It is a poor imitation of western models the “technological mis-fit”. The inadequacy of
which are not suited to a developing country. The this approach is highlighted in a recent WHO pa
focus on personal health care based on the services per which states, “There can be no question of
of a large number of highly trained physicians simply grafting on to a struggling and largely
and specialists is a capital intensive approach which agricultural economy, a high powered medical
57
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GUIDELINES FOR DEVELOPING ALTERNATIVE MODELS
system, with ultra-modern hospitals, specialist ned medical doctors will not automatically result
surgeries and general practitioners making house in optimal healthcare to rural populations or imp
calls”. What is needed is “adapt or improve upon rovement in health status of people. Thus the tra
existing systems but not adopt” as Mahler puts it. ditional model of the health care pyramid with a
There are features about the Chinese development, heavy top and narrow base, with the major invest
based on communes and using a large number of ment of resources in specialists, large urban hospitals
simply trained medical auxiliaries or “barefoot and sophisticated equipment and a narrow base of
doctor” to bring a health message as well as a minimal paramedical support is almost obsolete.
treatment and prophylactic resource to the rural The newer approaches envisage a model of a health
areas, that may prove suitable for adoption in care pyramid with a narrow top with some invest
developing countries. These countries cannot yet ment in doctors, hospitals, specialists, equipment,
achieve a full service in the lines used in the deve etc, and Jan enlarging base diverting investment
loped countries and well recognize their need to from a few large hospitals to several health centres
choose priorities. They can easily hinder their extending into the periphery with a broad base of
own progress by putting too large a part of limited primary care workers of various categories and
resources into training physicians rather than with emphasis on community organisation for
urger numbers of nurses, technicians, or auxiliaries health care. In fact, the dictum is “Health by the
people” and “health to people”. The ruling philo
provide a balanced health team.
sophy in this approach is not “Best for the few”
Attempts have been made in different projects but “good for the many”. However, this approach
in India to move away from the traditional model. is not to be interpreted as an effort to provide
A common innovation in all these endeavours is t
“inferior medicine to the rural poor” or “provid
select community workers of low education, train ing the underprivileged with second class medi
them for a range of simple health care task includ cine”.
ing health education, nutrition education and
In the absence of a universally acceptable
environmental sanitation and use them to supple alternative model, an attempt is made to list the
ment the available health care personnel. China basic requirements, preconditions and criteria for
has developed its own approach to health care a suitable model and to suggest some combination
delivery and has succeeded in its policy to break or strategies in different approaches to health
. down the conventional system of health worker’s care delivery.
roles and institutions and tried to develop a new
Some of the important guidelines in designing
labour intensive model which suits the needs of its
predominantly rural population and the overall alternative approaches are listed below :
goals of economic development. Basic to all such
1. The alternative approach should give pri
efforts has been an explicit recognition of the casmary attention to vulnerable and deprived
al link between health services and increased
segments of the population-women in child
..reduction. In fact the Chinese view is diameteribearing
age, children below five years, the
cally opposite to the view of western economists
poor
and
indigent, urban slum dwellers
who hold that health is a “Consumption” expen
and
those
who
have no access to any form
diture rather than a “production” investment. In
of
health
care.
most experiments with alternative approaches,
2. The alternative must be planned on an
there is also a recognition of the need to provide
appreciation of the multifactorial nature of
basic curative health care and simultaneously im
health. Health is a product of sound, heal
prove the environmental health, sanitation and
thful living, adequate nutrition, a proper
safe water supply. Several health projects round
understanding of one’s own body levels of
the world, recognizing? the needf for simultaneous
general education, environmental sanita
action on both the fronts, have experimented with
tion, hygienic methods of living etc. The
strategies based on mobilization of community
inputs
in the alternative strategy must be
resources for improving environmental sanitation
based
on
this appreciation.
and use of community health workers for deliver
ing primary health care. There is an increasing
3. The alternative approach should be built
recognition that more increase in number of traiupon the principle that health planning is
59
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OF MEDICAL PRACTICE
8th Edition
6th Edition (N.B.T.)
50
GUID ELINES FOK DEVELOPING ALTERNATIVE MODELS
8. Any concern for initiating alternative
an integral part of the process of economic
approaches must consider the problem in
development planning. Thus, in the new
the larger perspective of its antecedents
system primary health care activities sho
and linkages in the training programmes
uld form an integral part of the national
health system and community development
of health personnel. Tanzania and China
activities, such as education, adult literacy,
made simultaneous changes in the medical
education curricula and training methodo
agriculture, housing and communication.
logy to give emphasis on rural health and
This needs multi-sectoral planning and an
primary health care when the strategy of
application of the importance of non-health
using community workers and bare foot
interventions for health system.
doctors was launched. In this connection
4. The overall philosophy of the alternative
the Shrivastav Committee’s recommenda
approach must be to identify and make use
tion of medical college taking over PHCs
of available persons in the community, who
to use for student training is a worthwhile
are interested, enthusiastic and willing to
step that needs immediate implementation.
engage in health-related task. In addition,
The possibility of using the sites of alter
already existing health worker like the
native experiments for medical student
dai, practitioners of indigenous systems of
training must be explored. Government
medicine may be suitably trained and utili
Erskine Hospital Project, Mallur and
zed. Niger project in Tanzania, and Miraj
Medicare Plan are already trying this.
in India have successfully used the traditio
9. The alternative approaches to be developed
nal birth attendents and the indigenous
must adopt a service-cum-research appro
medical practitioners.
ach. This implies the need to develop conti
5. The persons who enjoy the confidence of
nuous monitoring, evaluation system and
the community and are considered as
a viable management information system
sources for health care must be utilized.
to ensure effective feedback. There is a
Categories identified by the Committee on
need to develop other indicators or impact
Medical Education and Support Man
of the new approach than mere service
power are the village post-masters gram
statistics and performance data. To the
sevikas, school teachers and dais. Alter
extent the new approaches need to be
native approaches should use these func
carefully evaluated for their replicability,
tionaries for primary health care tasks.
the emphasis should be on the process
rather than the product.
6. Instead of relying entirely on imported
technologies, attempts must be made to
10. Most of the Indian experiments seem to
combine the wisdom of traditional systems
owe their success to the devoted, charisma
tic leadership of the project chiefs. While
of medicine with the modern. It may be
recalled that the success in China’s health
this is understandable for demonstration
purposes, any large scale implementation
care delivery is attributable at least in part
to this strategy.
of tested alternatives must prove their
feasibility and success over and above de
7. The experiments on alternative approach
voted leadership. This will be an impor
es must as far as possible give a trial to the
tant issue in the sustenance of the initial
new health policies and strategies initiated
success of the projects and therefore an
by the Ministry of Health and Family
important criteria for planning alternative
Planning, Government of India. The Miraj
strategies.
Project giving a trial to the Multipurpose
11. There is a need to rationalise through ex
Workers’ scheme, and the Rehbar-i-Sehat
perimentation and evaluation the number
at Jammu and Kashmir and the Indian
of
tiers needed in-between the village level
Council of Medical Research (ICMR) fun
worker
and the other health personnel.
ded projects trying out school teachers for
12. While it is good to encourage novelty and
delivery of health care are illustrative of
innovation in alternative health care delivthis point.
61
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62
A
GUIDELINES FOR DEVELOPING ALTERNATIVE MODELS
16. The approach should be built on continu
ery strategies, there is also a need to retain
ous, sustained and effective community
certain common parameters in their me
involvement and should continuously aim
thodology to ensure comparability. There
at evolving innovative strategies for maxi
is a need for baseline measures, concurrent
mum community involvement. The nature
evaluation and contextual studies in order
and extent of community involvement must
to estimate the usefulness of one particular
be periodically evaluated.
approach vis-a-vis others.
13.
1^.
15.
Common to all models or approaches is
the need for standardization of basic edu
cational requirement for voluntary com
munity workers, core training content,
manuals and instructions, specification of
task and roles for each category of worker,
drugs and equipment, built-in supervisory
mechanism, system of continuing education
and referral system.
Thus the three basic components in any
model are (i) strengthening the infrastruc
ture (ii) integrated development of health
services and health manpower through
training and (iii) improvement of environ
mental sanitation.
Primary health care in any model or appr
oach should cover minimal treatment of
minor injuries, health education, education
to pregnant and nursing mothers, immuni
zation for children, nutrition education,
family planning and some action for provi
sion of safe water supply, building latrines
and waste disposal system. In addition to
curative services, the approach must lay
emphasis on preventive, promotive and
rehabilitative aspects.
17.
The approach should be effective in terms
of cost, technique and organisation.
18.
The approach must be based on the local
funds rather than relying too much on
external funds.
19.
It must be broad based and flexible in
order to absorb change.
20.
The approach must be based on locally
available'resources and expertise, but must
work in close coordination with the existing
government infrastructure and voluntary
agencies in the area.
21.
The overall purpose of the approach should
be to increase accessibility to health care,
particularly in rural areas, and to vulnera
ble target population identified earlier.
22.
Regardless of the approach an important
issue is the career promotion aspect of the
community health workers in order to
sustain their motivation. In some countr
ies, these workers can gradually reach medi
cal colleges after several years of service.
In Nepal, female health aids can become
Auxiliary Nurse Midwives (ANMS).
63
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64
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COMWJNITY health c.u
_
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A
SAMM^u..t -560 001
Why are our rural health
services so ineffective ?
A FTER our commitment, in
TV terms of the Alma-Ata
By J4GAD1SH C. BHATIA
were sponsored and Initiated by
the Government and there has
been no serious effort to involve
the people in decision making pro
cess and in the mobilisation of
local resources. Our pronounce
ments
and their dissemination
through mass media have gene
rated more consciousness among
the people, about their rights than
their duties.
This has further
dampened their will to partici
pate actively in. the various health
programmes. This weakening of
the capacity of local communi
ties to solve
their own health
r._
and our inability to
problems
meet their insatiable demand for
has resulted in
health services
dissatisfaction
and
frustration
with Govemment health program
mes.
Declaration, to provide
tions. it Is difficult to answer tills mentioned ^ve^ were.^abUshcare to all by the year 200' question precisely. However, spo- ed on the principle of integration
evidence does show that our of health services. They are supAD, the rural health service radic
heaith services have not been posed to provide seven types of
considered
has become a subject of topical
services which
interest in our country.
wpulation
nisation (WHO).
Studies have,
Several factors contribute this rural
rurft^
population.
Although
the Primary Health however, shown that doctors hardinterest First, 80 per cent of our Centres
----- 7have
—
in existence Jy .spend any tune in preventive
population live in the country- Centres have been
been in
for the last 30 years, their utili- and promotive care. Maternal
side; Secondly, more than 70 per sation bv the community has been and child health services remain
Tmt of our national income
curative
i poor. Studies of medical neglected. Apart fromi nn-atiup
om the rural sector and rather’ poor.
Cc«
in India conducted services, the only other activity
ell known
that “health care
care services
r
—
it ...
such
attention
the World Health Organisation which receives s’
+. . + is
effect” contributes in a major way by
the Johns Hopkins University family planning work and this too
to the economy.
Research Projects for obvious reasons.
’whelming Rural
overwhelming
. Health
In spite u£
of the ovei
xxda UxJ
National Institute of
Our internship and other trainof th..
the rural sector to tt
apd/J
16
importance c"
Health Administration and Edu- Ing programmes have also not
our economy, this is the most neg cuUvxx
hxJh^te
Indicate that only 10 to succeeded m changing the attllected segment of the population cation
20 per cent of the villagers utilise tudes of young doctors to rural
No integral ion
so far as health and medical care ~ 1
<-< x.__ixt. ----- health services. If choice is given
facilities are concerned. While 80 Governmental health services.
to them, they will not be prepared
per cent of the population live in
(4) There has been no serious
VCUA ,
CVtJA
to go to rural areas;
even those
Aware noM
the countryside, 80 per cent of the
effort to assess the health needs
who, pressed
’by circumstances,
’
‘
doctors have settled
down in
with PHCs work of the people and the effective
take up jobs
Furthermore, awareness
and
use haif-heartediy and are not able to ways of
needs. The
urban areas.
__
- nmeeting
„ those
11..c
f/A
r\ ’cnnord-riin
qmH
Further, there are intra-rural of. fchese
facilities
is
limited
to
g
a
j
n
the
confidence
of At-,.-.
the rural people
’s acceptance
and co-opethese
imbalance of services as functio- vipaggs
have been much
villages where these services
.services are people which is so necessary for ration would
nally much of the available man- loca
ted. People living 4in
the success of
any community ,Jeasier to obtain if health pro
1™^.
- the peri- thpower of either systems is distil- pheral villages either are unaware development programme. Rural grammes were geared to their felt
buted In bigger villages. The smal- of these services or find it diffi- services are always
*
1regarded by needs. Furthermore, no attempt
ler and “difficult to reach vil- culfc
"" made -----„.i because of them as a stop-gap arrangement ™
cult (/O
to reaeh
reach them
has ubeen
on a wider scale
lages have no facilities wnatso- communication difficulties and a
nd so they always try to get out to investigate
and
community reacever.
Furthermore.
available distance. The image of TH'"
1 earliest opportunity availa- *tions
’--------to the programmes. Byand
PHCs has at the,
estimates in India show that by al‘s0 been foim(i
0Jbe poor
poor., Even ble. Furthermore' the ‘'contents large, there is lack of sensitivity
luiuid tLu
rural -urban break-up of services, ain0Ug a small proportion of
rural-urban
„ vil... of our
_ training
_ programme are not and awareness
.
on the part of
have'' used th?"*'
those fnr,i
fact- based cn
on —
a i-eiFlistic appraisal z"
of health workers to social and emothe urban population has 8-10 Fagers* who h~.V2
times more --------------------institutional , facilities
jities,
the
majority
have shown
needs wx
of the
tional considerations.
lib
AVO,
VI AC lllCVJ
V/A AV.y
t. —
4AVVUQ
UA*v community and tasks
dissatisfaction with the services, to be performed.
and 12 times more hospital beds, dissatisfaction'
(5) There has been no proper
Although
there has been a con- m
ainlv
of
non-availabilir
•’ iaxvm
"-vuxvc
’ - t^u.
’
ma
in_ |y because
Thv
m*
The reasons for
the
ineffectiveand ^.youcu.a.Liu
systematic evaluation jjf^the
Ul.,
...
_____ .1 X3-_
siderable
improvement in Viziol+n
health
Of medicines
and
the rude .....a
and ness of rural health services in activities of Primary Health Cenmanpower in India
during the impersonal behaviour of the doc- India are many and not fax’ to tres which could “have provided
last two decades, the rural-urban tors Apart from the doctors, the seek. Some of these can be sum- guidelines4 for improving the
rat’- ’has remarkably remained peripheral health services have a marised as under:
: functioning of these rural health
in
Jged. Therefore, it becomes fotterv of paramedical personnel
----- of
r our health services institutions.
(1) —
Most
necc^.retry
- to
— ....
.itry for our ------society
be like basic health workers, vacci- -----have grown
at
random
based
on
------- -L —4-^ *------ —i
<6> Health care cannot be the
concerned about the health of its nators, auxilliary nurse midwives, intuitive judgments and depend- responsibility of a Health Depart
rural people. Politically, too. peo’ family'
familyplanning
Ing upon the urgency of certain ment alone. The activities of other
planningworkers, etc.
ple are demanding higher living
*7—T* Thc&c
uxxxpuxjjv
These unipurpose
workers are now problems and availability of r.e- institutions also contribute to the
standards on some equitable basks being changed to multipurpose sources — physical, financial and health status of individuals. There
and reduction 1~
.„„ manpower. There has rarely been has been no proper integration
in economic and workers, who are supposed to rpay
social inequalities. There are ris- domiciliary visits regularly in all a clear perspective and scientific with other development depart—--- -—
- x_ to«—
» „ a solutiontc to the
•ctations
Ing expectations
1’ ‘ respective
------ —
.
.
for social ser- ^^e villages in their
experimentation
with various—a-p-----ments
find
vxue,
xiivi
uvuxxj,
vice,
including
health services, areas.
r
including
areas. A large proportion of peoproaches to the delivery of health health
problems
. .
of the people
both in tenns> of quality and pj
o]e jn the rural areas have been care services.
and bring about an improvement
Quantity.
in their health status.
found to be unaware of their
(7.) In our Plans the health sec
many villagers
TVb unanimity
existence. Thus
tor generally . gets a low priority,
continue
be
by IndiComprehensive
----------toMedical
... attended
1
genous
Practitioners
(2)
(2) There
There has
has been
been no clear and inadequate resources in terms
Governmental medical care fa- (IMPs). These IMPs i.._
are -J.,
not, definition of the role and respon- of staff, equipment and drugs etc.
cilities available in the
v..,. rural areas
however, those
ilUWVVCl,
VXXVOV who use traditlosibilities of' the PHC doctor and
1 have? affected the efficient functhus far are mainly through the nal herbs, oils and Incantatons
’
-Interviews
■
incantatons other fuxxutiuxx
tioning of our rural health instifunctionaries.
Primary Health Centres (PHCs).. emu
and nave
have little
ixui
or nothing to do carried out by
./
Johns Hopkins tutions.
These PHCs were established as with modern
medicine. On t.ho
the University researchers
(8> Our
p
researcliers with the
preoccupation
with
a part of community development other hand, they are increasingly administrators of health and me- family planning and target setting
programme, way back in 1953,
to
using
modern
1952,
medicines. Their dical
di cal services in the Stxtc
State —
mid
-d in thiz
this regard has
her resulted h?
in tthe
K*?
provide comprehensive health ser- number is estimated to be about Central Governments and officials neglect of many more important
vices which,* inter-alia, included: <'•"
400,000 <one for every
popu„. 1300
directly
involved in the local super- health activities. This has, to a
medical relief, control of com- lation as againstr one qualified vision of Primary Health Centres large extent, alienated our rural
municable diseases, f--*
—
- doctor of modern system of medl- themselves have revealed that population which has been detrienvironmentai sanitation, maternity and child cine for 4700
'"30 population), of each has a different perspective of'' mental to
the family planning
health, including family. planning,
.
course with
c.
considerable
inter- a Primary
Health Centre and programme itself.
The family
school health. health
rip«uvh education
t7uuv<%tlu.u state variations. These IMPs are there is no unanimity of opinion planning programmes would havt
and vital statistics. Later, addi- very popular among rural people on the
effective anc
” functions
"
” PHC
’ is
’ sup- *been much
’ more
’’
the
tion in their activities and expan- and their ranks are being aug- posed to perform and the actual sustainable if they had been cloflion of many vertical health pro- mented every day. This “means role of the Primary Health Centre sely linked with other health proHgrammes resulted in a substantial that rural people are rapidly be- doctor. There has thus been a motion activities.
—increase in staff numbering from coming aware of
of the
the miracles
miracles pospos- complete
ane
complete role
role ambiguity
ambiguity and
and role
role(9) The vertical programmes
10-12, when initially started, to sible through modem
modern medicine crisis which has seriously affec- multiplicity of workers had re40-50.
and they like modern and allo- ted the planning and implemensuited .only
implei—„ _____
.
. in confusion and reWhat has been the impact of pathic modes of treatment but not tation of various rural health
health pro- sentment
x
x among the people.
(10) Our dogmatic adherence tc
these PHCs on the health status the doctors of the allopathic sys- grammes and the performance of’
(._
_r>aiio4
of the people? In the absence of tern of medicine available at the PHC doctor and other staff mem- so-called “medical standards” has
any scientific effort
<
my
to evaluate Government health facilities.
bers.
impact of these instituthe real Impact
The Primary Health Centres, as
(3> Most of our health schemes
(Continued on Page 8)
ex
aa
Rural health
*
service
(Continued from Pa^e 6)
blinded us to the actual health
conditions prevalent in the coun
tryside. We have failed to tap the
abundant sources of indigenous
medical care available in the rural
areas and use them for the pro
motion of various health program
mes. Instead of earning the goodwill and enlisting the co-operation»
of these indigenous medicine prac
titioners who. by and large, are'
very influential among the rural
people, we have antagonised them
with our various pronouncements
and activities.
(11) The social science and
management component of our
training programmes
has been
minimal and. to say the least,
superfluous. The Social and Pre
ventive Departments of medical
colleges who are primarily res
ponsible for imparting this train
ing have not received the status
and prestige they deserve and the
implementation of the training
programmes to that extent has
left much to be desired. They
have not been able to mobilise
multidisciplinary teams which are
so essential for imparting this
type of training. The effort to
organise inservice training pro
grammes for different categories
of health persoimel have been
only sporadic and thus ineffective.
There has been more emphasis on
didactic teaching rather than ex
posing the trainees to the actual
field situations.
Tire above, by no means, is an
exhaustive list of reasons for the
tardy development and ineffective
ness of our rural health services.
Systematic research would, per
haps. bring out many more fac
tors to help us take necessary re
medial measures and reorient our
health programmes and activities
taking into account the needs of
rural communities and our com
mitments in terms of the AlmaAta Declaration.
4
DELIVERY OF PACKAGE OF HEALTH
SERVICES THROUGH
MULTI-PURPOSE HEALTH
WORKERS’ SCHEME
Dr. E. S. RA0HAVENDRA RAO, m.b.,b.s., b.s.sc.,
(Assistant Director of Health Services & Family Planning)
PRINCIPAL,
Health & Family Planning Training Centre, Salem.
1.
More & more advancements in Medical Research might lead us to a
complacent thinking that Science has finally won the fight against disease.
2. In a welfare society with a socialistic outlook and approach, all roads shall
lead only towards the goal of greatest good of humanity at large.
3.
Not only the Educational and Examination Systems of the Training of
Medical and Paramedical personnel but also the DELIVERY SYSTEM OF
THE HEALTH SERVICES, need^complete re-orientation and reorganisation.
4.
Epic Victories in the control of communicable Diseases, Exemplary
Achievements bringing down Maternal and Infant mortality by TECHNO
MEDICAL REVOLUTION, might disappear if adequate coverage of the
entire rural and urban populations is not planned by the Health Services.
5. With all humility we now venture to visualise the future INTER
FACED MEDICAL OFFICERS of the Primary Health Centres of Tamilnadu,
who are experts in ihe MULTI-DISCIPLINARY APPROACH TO DELIVERY
OF HEALTH SERVICES, including MEDICARE, MEDICAL EXTENSION,
FAMILY PLANNING and APPLIED NUTRITION.
6. Custom decrees, courtesy demands and curriculum compels that the
Medical Colleges and Teaching Hospitals turn out only well qualified INTER
FACED DOCTORS capable of tackling all medical and health problems
subject to availability of auxiliary assistance and other resources
7. It is of paramount importance and of pathetic urgency that we improve
the quality of Undergraduate Medical Education and Pre-Registration Internship
Training to Commensurate with the level of expectation of the Community.
8. Not withstanding the existing systems of examination and evaluation at
the Internship level complaints are not uncommon that the turnouts are
substandard in qualitative training and hence there shall be yet another system
of Competence Measurement and Merit Rating, Grading or Assessment at the level
of Internship also. However unorthodox the suggestion be, criteria need be codified
for Competence Measurement of Government Medical Officers at periodic intervals.
9.
4
Use-effectiveness of METHODS employed in the Delivery of Comprehen
sive Health Care needs evaluation at every level.
10. Through knowledge in COST BENEFIT ANALYSES coupled with
Organisation and Methods Study, Operational Research, Productivity Techniques,
Supervision Skills Development, Man Management, Materials Management,
Methods Management and Money Management, is a MUST for every
Medical Officer of a Primary Health Centre.
11. The medical Officer is the “King Pin” of the P. H. C. He shall equip
himself with. TECHNO-MANAGERIAL CAPACITIES and then only Producti
vity, Profitability and Public Satisfaction would follow.
12. Abundant experience in Curative Medicine alone will not turn out
Interfaced Medical Officers. Adequate Exposure to Field Work as the Head of
a “HEALTH TEAM” would make him an instant success in the practice of
Community Medicine.
13. India now needs no Glamour Medicine nor Spare-part Surgery.
Privileged few only are admitted and treated in the most sophisticated Tower
Blocks of Teaching Hospitals. Common Man cries not for “Heart Exchanges”
but for “Change of Heart” among Medical and Paramedical personnel. Lip
service to his ‘FELT NEEDS” amounts to a cruel joke on his crippled
mind and body.
14. HOSPITAL ATTENDANCE does not reflect MORBIDITY in the COM
MUNITY. Every disease exhibits an “ICEBERG PHENOMENON”
15.
For Conducting Morbidity Surveys and for giving greater EMPHASIS,
than Curative Care,
On Preventive Care
than Late Diagnosis,
On Early Diagnosis
than Clinic Contact,
On Home Contact
On Continuous Patient care than Episodic Patient care
“Health Team Approach” is more suitable than “Hospital Approach”
k
)=
16.
For the Domiciliary Follow
up of Environmental Diieases such as
“PULMONARY TUBERCULOSIS.”
HYPO - PROTEINAEMIA,
SEPTIC ABORTION ETC.,
and for the follow up of defaulters and terminal cases; of Cancer Clinic, as
Low-Birth Weight
well as for the early discharged post-operative cases and
a
infants etc., Health Team Approach would be welcome.
To achieve the objective of taking medical care and diagnosis to the
periphery, through the Health Team, it is essential that there shall be a
17.
built-in system of supervisory checks between all the members of the Health
Team to maintain quality and for effecting maximum delegation of respon
sibility to those with minimum training, consistent with good care, supported
by excellent communications and medical back up from the main Centre.
Under the over all supervision of the Medical Officer-in-charge of the
main centre and the Public Health Nurse, 80% of subcentre practice can be
18.
delegated to paramedical members of the team. “Daily subcentre-clinics
conducted by the A. N. M. are meant for the management of minor clinical
ailments, apart from M
C. H. services.
“ Weekly
Referral
Clinics ”
are
to be conducted by the Medical Officer in the subcentre itself.
19. For the Assessment of community health levels, Identification of com
munity health needs. Appreciation of community resources-private and Official,
Coordination of the work of professional health leaders at local level,
Supervision of the work of A. N. Ms, Constant training of field workers and
for Delivery of services
in the improvised set up, the Public Health Nurse
has a major role to play.
20.
The logistics on which Government Health Services are formulated
are totally different from those of the Teaching Institutions. Medical Educa
tion is so much dominated by individual specializations that it cannot be
photocopied or portrayed in the community within its economic capacity.
As the quality of Health Services depends on the efficiency with which their
Delivery System functions it is imperative that we develop a Multi-purpose
Health Workers’ Scheme.
MULTI PURPOSE HEALTH WORKERS’ SCHEME
The Steering Committee on “Health, Family Planning,
Nutrition9' of Planning Commission has stressed on the following :
i) Proper integration of Health and Family Planning and
Nutrition Programmes as such integration is more effective
and economical
ii) Entrusting Multi-Purpose Workers to discharge
integrated functions.
such
Hi) Providing 3 categories of such Health Auxiliaries :
iv)
a)
at lowest level - Basic Health Workers or ANM,
b)
at intermediary level-Health Visitor or Health Inspector.
c)
at higher level - Health Supervisor.
To arrive at an effective pattern of services from Operational
and Training angle.
“The All India Committee on Multi-purpose Workers has
given their recommendations, for settingup Multi-purpose Workers
in rural areas of the country”. Their main recommendations are:
A
o
Ultimate objective is to have one “sub-centre” for every
3000 to 3500 Population; to group 4, sub-centres into a sector,
to have one Health Centre for 4 such sectors.
ii)
Multi-purpose Workers at lowest level are to be supervised
by multi-purpose Supervisors at various levels up to State
level.
Hi)
Implementation can be phased depending on availability of
personnel:
a)
First phase can be to introduce the scheme where Malaria
Eradication Programme and Smallpox Eradication Pro
gramme have entered into ^Maintenance Phase”.
b)
Second Phase can be to extend this to areas which enter
into maintenance.
c)
Third phase will be to have this scheme throughout the rural
areas of the State incorporating all “Health” Programmes.
iv) Job based training is to be given to each of the Workers to
equip them technically to discharge their work;
v)
The Dispensaries lying within the jurisdiction of a Health
Centre, are to be linked with the Health Centre and subcentre
staff shall utilise the Dispensaries to refer the cases.
vi)
The training given in “Medical Colleges” shall be modified
to equip their trainees to deliver such integrated services.
23. Government of Tamilnadu for their part have been making some
headway in implementing the Multipurpose Health Workers’ Scheme. The
erstwhile “Regional Family Planning Training Centres” have been redesignated
as “Health and Family Planning Training Centres”. They have now been
equipped to train Basic Health Personnel in ‘First Aid’. ‘Laboratories’ have also
been equipped to train personnel. Altered Staff pattern to include Sanitarians
and Laboratory Technicians is under consideration of the Government.
24. Test Courses on Multipurpose Scheme have been conducted in the
HFPTCs Salem and Gandhigram. Since the Government have thought fit
to implement the scheme as a “Pilot Project” first in Kanyakumari District,
Gandhigram Institute of Rural Health had already constructed a Model
Curriculum to train the Medical Officers and Block Extension Educators (To be
redesignated as Block Health Supervisors) so that they will take up the Role of
Trainers for other echelons of staff in their own Primary Health Centres.
25. Bottle necks are seen at every stage of implementing the Programme.
Planning for the judicious redistribution of the functioning Unipurpose Workers
in the proposed multipurpose set up is upset either due to excess of male
workers or due to near total absence of Maternity Staff under the Directorate
of Health Services and Family Planning.
26- Anamolous situation in Tamilnadu is that the existing Maternity Staff
are mainly working under the Panchayat
union’s Administrative Control
although to a certain extent technical control over them is vested with the staff
of the District Health Officer. The District Family Planning and Maternity and
Child Health Officer has got the MCH component only in the official designation.
Inter departmental conferences between the Directorate of Health Services and
the Directorate of Rural Development only can suggest to the Government ways &
means for transfering the Maternity Staff to the Health Services.
27. Unipurpose Vertical Programme Directors have to Compromise their
Unitarian Authority at the alter of the Multipurpose Horizontal Programme
proposed to be implemented. While some of them welcome the new set up,
others caution that dire consequences might follow if the supra-structure of
Block, Divisional, District and Regional level Supervisory Officers, well trained
in the Logistics and Modus Operand! of all the Component Programmes are
not posted and optimal standards are not expected out of the Multi Purpose
Health Workers. Ill-equipped, Unsuitable and Unwilling Officers, if posted
even in a promoted position of importance, might “Punish” the Programme
and the Public, by their lack of Motivation to try out this innovative, well
meant but hard to implement Programme.
28. Officers, with no local level authority delegations to solve staff and
teething' problems might unknowingly sabotage the very Objectives of the
programme.
’I
I
29.
4
Proper Training envisages that
a)
Concepts of the Multipurpose Health Workers’ Scheme,
b)
Principles and Practice of Health Administration,
c)
Principles and Practice of Epidemiology,
d)
Implementation of National Malaria Eradiction Programme,
National Small Pox Eradidion Programme,
n
National Tuberculosis Control Programme,
jj
National Leprosy Control Programme,
National Family Planning Programme &
ir
other National Health Programmes,
e)
Modern
9
Problems of Environmental Sanitation,
g)
Compilation and Analyses of Vital & Health Statistics,
h)
Unitary and Referral Diagnostic Laboratory Services, &
i)
Principles and Practice of Communication
Health Education, Techniques and aids,
methodologies of Maternal
& Child Health Statistics^
and
Community
are all to be synthesised and systematically taught to all the erstwhile Uni
purpose Workers and their Unipurpose Supervisors.
*
30. Elimination of Wasteful Practices in the compilation of Base Line
Data which is unnecessarily duplicated by every Unipurpose Programme and
avoidance of many people visiting a unit area for Supervision of a small facet of
Health Work, might permit us to afford a better equipped Supervisory System and
eventually prove to be less costly and more remunerative in Health Status
returns.
31 Coming to Cross Roads, three Questions may now be posed about the
implementation of Multipurpose Health Scheme.
r
1.
2.
3.
Is it easy ?
Is it possible?
Is it worth while ?
32. How we wish your Answers for the
be as per the following order.
1.
2.
3.
above three Questions would
Not quite easy.
Possible if you have the determination.
Definitely so.
I
Copies Can Be Had From
PUBLICATIONS WING
Health and Family Planning Training Centre
Salem-636001
4
*
T.r
►
Go no H
GENERAL APPROACH TO RURAL COMMUNITY HEALTH SERVICES
Fundamentally, the health services have to be viewed in the
context of overall integrated development of the villages. Health
services cannot be fully successful if they are pursued in isolation
from the general development activities of the area.
i baseband population
The community health services must be area
of health
services to the total
based — providing the total spectrum c.
-a defined geographic area. Primary health care must
populace living in
be available at the doorstep of the receipients.
1. Area Coverage — Regionalization:
We must accept responsibilities to provide health coverage to
the population of a defined area.
Selection criteria of the area:
A) Nged -
Poverty and illiteracy
high incidence of diseases
non-availability of health services.
■
B) Suitability
uiu not
nvu be
— too far nor‘ should the area
The area should,
to/®B6a«
the city
be too near
---- — then the people will be vrsiting
for their health needs.
the city
Assurance by the community for aiifull cooperation and
help.
If thereOis?an°already1existing useful organisation that can
provide us useful assistance.
If the village is well united and
panchayat.
there is an effective
. 2 2 % Tx- 4-up villaae has. or is willing to immediately start, a
} yf^age Health Co^ittee, which could help us in several ways,
actino as an efiective link between the health workers and the
villaoers. Such a health committee should preferably be consi
dered^ specialized organ of the panchayat unless the panchayat
is divided and ineffective. Then the Village Health Committee
can be an independent institution. But it must enjoy the
confidence of the entire village population.
a a Contd/2-
..2/to contribute their share
iv) If the villagers are willing
by:
1 Agreeing to pay a small insurance charge
2* Agreeing to do Shramdan for some health projects
3* Agreeing to contribute volunteers that will help
run the health programme.
’ ’ available about that.area due
v) If some date is already
on-going
to previous or c
— survey etc., either in connection with a health programme or as a part of general
development activities.
2. Total Population Coverage:
The whole population must be covered.
PrioritiestThe weak and the vulnerable:
Nursing mothers
Promotion of health and prevention of disease.
Nutrition, Sanitation, Immunisations & Health Fducation
Adequate simple records.
3* "Health Insurance11:
Every body pays.
a graded scale, depending upon the economic
There may be
1
status.
Advantages:Greater interest taken by the community.
Greater community participation.
+hpir
People feel they own the programme-and it is their
(as indeed it always should be).
People who pay can also ask for good services, and
who can complain if the services are not good.
Keeping accounts develops the idea of accountability.
People‘'do not value the treatment that is 9^en free.
They may even throw away expensive drugs, thinking
them worthless.
.
,
Getting things free is not a good habit. It should
be discouraged.
a
x
Some people consider it ethically wrong to give »or
There is no such thing as FREE. If the villagers are
not paying for it, somebody else must be paying for it.
4. The National Context and Constraints:
Ours is a poor country.
Our health services should be affordable on a countiywide
basis, perhaps adding upto a few rupees per head oer
It is no use creating an IDEAL or achieving "excellence",
which cannot be copied on a large scale*
•. .Contd/3’
*
V
...3/in mind the replicability of our health
We must keepu in
We
be able t o demonstrate a pattern
services. V.’- should
of health care
’
TO yeaK^bit
Thus our efforts should have national relevance.
We
have wasted our opportunity if our health services and experience can
not be multiplied and does not have any relevance- for the creation of
effective health services on a country-wide basis.
5, Coordination with the- State Health Organisation,.
Health is a State subject.
We should avoid dual control or parallel and competing
health services. We should have a clear understading with the State
health Ministry and the District Chief Medical Officer. We should
clearly deine our respective roles and establish clear channels of
communications and cooperation.
Broadly, our plan for community health services should
follow the state pattern. We can fill in the lacunae and strengthen
weak link, but we should not drastically after the overall health plan
or health strategy. Otherwise we again face the risk of wasting our
opportunity and losing all relevance.
6# Utilisation of Existing community Resources,:
Indigenous and homeopathic practitioners Ordinary simple
They include:
home remedies.
The common lore and grandmas recipes Yoga.
Health practices of our people, such as personal cleanli
ness, boiling of milk, breast feeding of children self
reliance etc.
Local educated young men and women, including teachers,
post-man etc., that'can be roped in for various types
/we must never
of "help" that comes to villages.js©btrophy of local
aljbow
Iwadership and initiative and fostering an attitude of
dependance and passive acceptance. We must guard agains
the tendancy to pull people up by their ears, instead
of encouraging them to pull themselves up by their
boots-traps. We should resist all well intentioned
effort to spoonfeed the people.
....Contd/4-
*
Instead, we should encourage local leadership, local
initiative and self reliance. At a practical level,
we should select suitable educated young men and women
from the vil lages themselves, and train them as health
workers. We should also involve the community in all
health work, right from the stage of planning onwards.
9. Community Participation:
A community should consider the health services as
their own. Community participation is the sine qua
non of any successful community programme. This is
one reason why the community must pay for its health xkxvik
services partly, if not wholly.
The community must be involved in all stages of the
community health programme, including decision making.
Important areas of community participation:
planning*
Financial contributions.
Selection of workers from the community.
Evaluation of their work.
Village Health Committees can play a very useful role
here, as already mentioned.
10. Special Role of Health Education:
Health education is essential in a democratic set-up in
order to elicit the willing and enlightened cooperation of the people
It increases peoples competence to look after their own
health, thus fostering self-reliance.
It helps people take greater interest in their health
services.
It helps people identify incompetent workers or incorrect measures.
Everybody is interested in the working of his/her body,
and in health. They will pay attention if health education is imagin
atively carried out, using for example puppet shows, one act plays,
practical demonstrations, mobile exhibitions, etc.
The following topics should be covered:
First-aid
Simple nursing
Body knowledge
Contd/5-
5/Yoga
Personal hygiene
Balanced diet
Some simple preventive measures etc.
11. Phasing and Pilot projects:
We should start with a small area or start with only
a few services or both.
We should expand and multiply health services as we
gain more:
insight
experience
confidence
acceptability
efficiency
12. Essential Steps:
To Implement the Community Health Programme Objectiyes:
To create comprehensive integrated community health
services for the total population of defined rural areas,
with emphasised on vulnerable groups and on prevention.
Such a service should be made available on aregional basi
alongwith effective referral facilities.
Summary of Steps;
1. A managing committee
Surveys:
Health Programme should be
established, (if necessary)
2. Constituting a ’’Planning and Implementation1' Committee
for the Community Health Programme.
3. Selection of suitable area or areas of work. Selection
criteria already mentioned in the general approach.
4. To study the area(s) to define its problems and assets.
This will involve planning and conduction of surveys cover
ing the following variables:
Demographic
Socio-economic
Health - Existing problems
- Existing facilities
Contd/6-
Cor-o H CI- (O
CQM’&v&.jY 4,
CHA
A / h' G Al O * s E - 5 HQ qq |
THE GANDHIGIUM INSTITUTE OF 1TOAL HEALTH /IH) FAMILY PLOWING:
PO AMBATHUAA.I HS
:: ii
WDltAl DISTRICT
::
.LWMWr6242^.
ACTIOH-jlSSSJJtCH FQ2 O'aG.AMI^ATIObM> D.WELOBgT. : A ItESWCH Pi^OPOgAL
1. Title of the Study
2.
: ACTION RuSLAJlCH IN OllGWLATIOhAL
DEVELOPMuNT
Introduction
During the last few decades research in the field of formal organiza
tions has amply demonstrated that a number of structural and process vari
ables are directly related to organizational productivity and morale.
Likert (1961) has delineated some of the crucial variables that discrimi
nate between high and low productive organizations. Though many of these
studies are conducted in industrial and business enterprises with a market
orientation, the variables themselves seem, to be no less important in
determining productivity and morale in non-market but service oriented
bureaucratic systems.
It is a paradox that while organizational analysis started with the
classical work of Max Weber on Bureaucracy, very little has been done in
this area by wa}/ of intervention or action-research. To be sure, there
has been some work done in this area but not in the form of action-research.
Most of the studies are either discriptive or classificatory in nature.
One recent study bv Anthony Downs (1967) seems to go a little further by
providing a typology of Bureaucratic systems and bv formulating some
testable hypotheses about them. Nevertheless, his analysis shows that
considerable variation does occur within the so called rigid bureaucratic
systems due to variation in styles of leadership and demands of the
environment.
Bureaucratic systems are rapidly expanding and are tairing into their
fold many types of services for the public.
The quality and extent of
services rendered by these organizations are intimately interwoven with
the processor variables which are show to h?-ve direct bearing on produc
tivity in industrial and business organizations. Hence, there appears
to be an urgent need to study these variables and explore intervention
strategies for influencing these variables in order to promote producti
vity and morale.
Vi th this background in view it is pre osed to design and conduct
an action-research within a unit of the Public Health Organization in
Tamil Nadu. At the gross root level, it is the Primary Health Center
which directly deals with community services and is therefore significant
to focus our attention. Intervention at this level seems to have great
action potential which could be released by the application of scientific
procedures.
3.
Objectives and Scope
The study has two objectives :
(a) To study some of the processor variables and examine their
relationship if any to productivity of the Primary Health
Centers in Tamil Nadu.
(b) To initiate an Action Programme so as to influence some of the
relevant processor variables with an overall objective of
promoting efficiency and productivity of the Primary Health
Centers.
The proposed action-research will have two phases - A study phase
and intervention stage. The study phase would last about 12 months
and would be devoted to measure some of the significant variables related
to organizational performance at this gross root level.
The study phase
will cover all the 35 P-H.C. units of the Madurai District, Tamil Nadu.
The units will be first stratified into low and high on the basis of
cumulative record of performance in the family planning programme. The
selected organizational variables-, will be examined for their contribution
toward the performance. Variables which explain a significant propor
tions of variance and could be manipulated will be selected for inclusion
in the action programme.
The second phase of the study will be devoted to experimentation and
intervention.
This phase may include a training component and process
consultation as two of the possible strategies to promote organizational
development. Other strategies may include team, work & participation of
the field staff in decision-making and target setting etc. Role defini
tions, job specifications and training in principles of programme planning
could also be considered.
Our attempt could be to promote organizational
development as an effort to increase organizational effectiveness and
health through planned interventions that are based on behavioural science
knowledge and skill.
Through a review of literature in this field and by discussion with
knowledgeable persons about the nature and working of the Primary Health
Centres, certain processor variables are selected for the study,
variables selected for stud3ip are the following :
The
Role Congruence
Leadership style
Communication
(4) Participation in Decision-making
1J
2)
1>)
(5) Coordination
(6) Teain work
(7) P.H.C. work atmosphere including flexibility or
rigidity of rules etc.
(s) Worker attitudes including job satisfaction,
morale and Commitment.
3
In selecting these variables the following criteria were applied :
(a?.) T’le variables should have been shown to beer sone direct
relationship to productivity and morale in organizations.
(b) The variables should be mutable within the constraints
imposed on the organization from a higher level in the
hierarchy of the Public Health System.
The study phase will be com'fined to an examination of these eight
variables and their relationship to productivity at the Primary Health
Center level.
4.
Sampling design
It is proposed to collect data on the said variables from all the
Primary Health Centers in -Madurai /oV^Sail Nadu, numbering about 35.
No attempt will be made to sample the units as there are not many such
units.
However, the P.H.C. units will be later stratified into high and
low performance blocks and the selected processor variables vrill be
examined for their discriminative ability between high and low performance
blocks.
5.
Independent and Dependent Variables
For the purposes of this study the eight processor variables will be
our independent variables.
The dependent Variable will be the perfor
mance of the primary health centers.
These variables are operationally
defined as under :
A.
Independen t Vari ab1e s
(1) Role Congruence
Role congruence refers to the extent of concordance or agreement
between three selected dimensions of the role of a public health worker:
Role as prescribed by the organization and the role as perceived by the
worker himself; the role as prescribed or perceived and the role as
actually carried out in the organization.
Implicit in this analysis is
the assumption that the greater the congruence between the three dimen
sions, the more effective will be the performance.
In-congruence may lead
to axiety, guilt and even frustration in that role besides adversely
affecting performance.
The more diffused the job functions the greater
the role ambiguity and the more specific the job functions
the greater
the congruence among the dimensions.
The extent of role congruence can be measured b: using a checklist
of job functions or by eliciting job functions as perceived by the
incumbant of a position and his superior.
For example a completely
randomised list of functions relating to Medical Officer, the Block
Extension Educator. , the Sanitarian or the Health Visitor or the Health
4
Assistant can be administered to each one of them to check functions
which they consider are their role specific.
To the extent the functions
as perceived by Block Extension Educator and the Medical Officer agrees
there is role congruence between prescribed and perceived dimensions.
Similarly role or functions actually carried out and functions as per
ceived can be compared for congruence.
Alternatively, role congruence could be measured through the help
of an interview guide.
This may be better than using checklist which
may be suggestive or at best tap- simple yes-no answers at a superficial
level.
The interview has to be unstructured and therefore very skilled
interviewers have to he engaged for this purpose.
(2) Leadershi-p Style
The three dimensions that will be studied under this variable
are : (1) Work facilitation efforts; (2) Human Relations skills and
(3) Goal emphasis.
We may have to use different approaches or instruments
to measure each of these dimensions.
Whatever the approach or instrument
used, it is necessary to study this variable from subordinates point of
view or community point of view.
One approach and perhaps the most commonly used approach is to list
several items under each of the three dimensions of leadershi
a rating on a three or five point scale on each item.
and obtain
Such ratings can
be obtained by the immediate subordinates of an officer aid if possible
by other equals.
It is customary; to have an odd number of raters (? or 5)
so that the problem of equal, number rating one way as in the other way
does not create problem.
Village leaders or patients who had frequent
contacts may also be able to rate the Medical Officer.
Besides rating we can also observe the leadership style of atleast
the key figure (li.O.) over a one month period in a saiQple of situations
such as a staff meeting, supervisory conference, field inspection etc.
VJe can use a check-list or guide for such observations and assign marks.
This approach will give a measure independent of the bias of his subor
dinates.
Inter-rater agreement is as essential for the first as for the
second approach.
However, the latter being done by trained raters should
give better measure.
Either or both of the above approaches may be used in the area of
Human Relations skills.
In regard to the dimension of work Facilitation
Behaviour we may ask several important questions to selected subordinates
the answers to which when taken together indicate roughly work facilita
tion or block/behaviour.
How genuinely the Supervisor is interested in
hearing and understanding the work problems of his subordinates, how
5
often he helps by taking immediate and necessary follow-up action etc.
To be able to make this
may give some indication of this behaviour,
judgement workers should have a least a minimum of 6 months experience
The probable-respondents
of working under the particular supervisor.
could be sanitarian, the Health Visitor and the Block Extension Educator.
Goal emphasis may be treated as a part of work facilitation dimension as
they should go hand in hand to get productive outcomes•
vie can have some
items on this dimension in the same schedule.
(3) C piamuri i cation
When we talk of communication we are interested in communication
relating to planning and execution of health and family planning services
flow of work and efficiency of work and communication that helps in sound
decision-making.
For this to be achieved communication should be facili
With regard to upward
tated both upward and downward as well as sideward.
communication, the crucial questions can be whether the supervisors
encourage and seek programme relevant
information and whether they
do actually use such information in discussions about problems and
decisions to be made.
V/ith regard to downward communication the important
questions may relate to such issues as to what extent valuable information
is speedily communicated downward and to appropriate categories of person
nel, to what extent the personnel are well informed of expected changes
in programme, strategies or new assignments together with a rational basis
for such proposed changes etc.
Sideward communication may bo useful for
team work or coordination of effort.
For example the communication
between the Block Extension Educator and the Health Visitor or the
Sanitarian and the Auxiliary Nurse Midwife could help in programme
coordination at the field level.
The frequency of this communication
may be expected to be less than the frequency of downward or upward commu
nication unless the leader makes special efforts to facilitate this type
of communication.
Administration of a schedule or a questionnaire to selected respon
dent categories could give us some measure of this variable.
Bias in
reporting about upward communication is more likely to occur in such
a procedure.
Bias could also occur with regard to reporting on downward
communication probably with a lesser frequency.
Alternative method to
measure communication is to observe the organisational activities over
a period of fortnight or a month and record material relating to communi
cation.
Such observation can be made by Competent persons and every detail
should be recorded in a. process form before scording.
qualitative data has to be done very carefully.
Scoring of such
The question is whether
we will be able to get all relevant data in a short observation of the
organization process in one fortnight or a month.
If this method is
feasible it could provide a basis for comparing reported data on communi
cation.
6
( 4)
Pa.rticii3a.tion in decision-malring
While broad policy and administrative decisions are made at the
state or district level, the P.H.C. still would have considerable room
as to how to carryout the programme or what strategies could be adopted
to achieve the targets or goals set for the organization.
It is vital
that lower level field staff be adequately involved in making the'- ’vi
sions.
Their experience and insights could help a lot to making right
decisions or adopting appropriate strategies of action in the community.
The extent to which participation is sought or elicited can be
measured by the administration of a schedule.
It can also be measured
through observation of curtain processes - sta.ff meetings and group
discussions conducted at the P.H.C,
(5 & 6) Co o rd in a ti_o ri and Team, ffork
We may treat this as a single dimension if not as a single variable.
Coordination of work within the organization and coordination of work
with other outside organizations or departments are both essential for
effective results.
Team work implies a little more than coordination as
it is based on an understanding of complimentarity of Knowledge and skills
of two or more workers.
An appreciation for each specialist and a desire
to collaborate in solving health problems are basic for successful team work.
Measurement of coordination appears to be simpler than measurement
of team work.
In measuring coordination we ask such questions as to what
extent they work together with other agencies or individuals.
Whether
the P.H.C. staff work often along with the staff of the Panchayat Union,
whether they seek the help of such voluntary organizations as Madar ~
Sangams, Youth
Clubs etc. and whether they utilisethe resources of other
departments of
the government available in an areaetc.,
be measured by
such direct questions.
Team work cannot
Instead, wehave to ask a number
of indirect questions, the responses to which give some indication of use
of team concept in actual work situation.
For example we can ask certain
questions on the way programmes are actually implemented.
How is a D.T.P.
Programme organized and executed in a village - who are the professional
staff that participate ~ what does each professional or specialist do ~
Whether such specialists plan together so that they can share work respon
sibilities and equip themselves with needed materials etc«
Because of the tendency to give a socially desirable response, it
may be much better to use some other method of measurement.
Observation
of certain field programmes as they are carried out and observation of
certain planning sessions or staff meetings when plans are drawn out for
implementation of a programme could give us a measure of coordination and
7
iki observat'5 on guide could be used so that relevant infor
team work.
mation is recorded for giving scores later on.
(7)
Work atmeaphere including morale and commitment
Work atmosphere could be studied from the point of view of the
physical setting and also from the point of view of the social and psycho
logical climate within which work is to be carried out.
The physical
setting could include items like office accommodation, furniture, equip
ment needed to carry out job responsibilities, air and ventilation, pro
vision of living quarters etc.
quality of social relations
The social dimension could include
that exist among co-workers, the worker and
the supervisor, values, norms and attitudes relating to work etc.
Worker
attitudes, morale and commitment all seem to form a part of this dimension.
Only individual level job satisfaction has to be separated.
Physical dimension of the work atmosphere could be measured, through
observation and rating on a five point scale by the independent competent
The social and psychological dimension, however, has to be
researchers.
measured by depth interviews with selected categories of staff.
An
interview guide could be worked out for this purpose.
Some workers have tended to view morale as equivalent to individual
job satisfaction while others have viewed it as <?. property cf the group.
Yoder (1970:545-568) has presented an enlightening discussion on the
variables of commitment and morale.
Commitment according to him consists
of a syndrome of attitudes, understanding and feelings that identify the
team-dedicated participant.
Morale means ’’evident commitment” i.e. exhi
biting the behavioural symbols and symptoms of personal commitment.
When morale is viewed as a property of the group as distinct from
individual job satisfaction, the emphasis is on social reactions and on
attitudes toward group values rather than toward individual values.
Feelings
cohesiveness, sense of belonging and interest in wooing
toward group task goals are important elements of commitment or morale.
The morale syndrome can be measured through behavioural indicators
which are explicit or those which are implicit.
The explicit aspect
could be noticed through what the individuals speak, write or say in
response to a questionnaire.
The implicit dimension has to be inferred
from such indicators as absenteeism, turnover, sluggishmens in work,
disciplinary problems, restriction on output etc.
It is obvious that we
can use an interview schedule as well as rate the level of morale in an
organization by independently observing the objective behavioural indicators
specified above.
The interview schedule may include measures of cohesi
veness, sense of belonging and commitment to task (programme) as well as
organization.
It is not known to what extent commitment to one is inde
pendent of commitment to the other.
8
and Rigididy of the system
(8)
Independent of the leadership style, the organization may have
imposed certain constraints that could affect the efficiency of work.
We have to ask ourselves flexibility in what respects or rigidity in what
aspects of the structure or process, Rules and regulations regarding
recruitment, transfer or promotion of personnel ap-ear to bo restrictive
on the Medical Officer. So also some procedures to be followed for pur
chase of equipment, repairs to existing equipment” are rather restrictive.
The program target set at higher level arc restrictive in certain respects.
Apart from such restrictions there appears to be considerable freedom to
the Medical Officer to organize, direct and conduct the programmes of
public health and family planning.
However, the rewards or punishments
he could offer for doing or not doing good work are very limited.
He has
to play on the psychological or social needs of workers to motivate them
in the absence of powers to administer economic rewards or punishments
The areas of flexibility and rigidity could be studied through inten
sive interviewing in selected dimensions of work and administration.
Existing rules and procedures for the functioning of the organization and
powers of the Medical Officer could also be studied.
Area.~vn.se rating
on a five point scale with regard to flexibility and rigidity could be
attempted.
But the basic question we have to answer is whether or not
this variable isconstant across P.H.C. units.
If it is so, the question
to ask is how the flexibility of the system.is exploited by the Medical
Officer., for effective work.
B.
The Dependent Variable
For the purpose of this study the dependent variable will be the
work turned out by the staff of the primary health centre in the health
and family planning programmes.
Cumulative performance over a three year
period immediately preceding the date of survey will be considered.
Both
the quality, and quantity of work turned out i.e. performance will be
considered.
Some indices for quality and quantity of work turned out in
the following areas will bo developed and used :
1. Medical c.«re services
2. Communicable disease control
3. Environmental sanitation'
4. M.C.H. services
5. Fanil” Planning services
9
C. Control Vari^bl^s
In Avamin-ing the relationship between processor variables and the
performance of a P.H.C. , we have to control for the effect of other varia
bles like input variables and the environmental variables like the levels
of socio-economic development.
Though we are not directly measuring
these variables we have information on these variables from another study
which we could use at the time of analysis of data.
We have data on input
variables like man-months of supervisory and subordinate personnel,
vehicle mileage, money spent etc. and on socio-economic variables on the
We can examine how much of variance in performance
concerned blocks.
is explained by socio-economic variables, input variables and processor
variables separately and together by all of them.
6.
Expected Relationships be^^^Indejjendent
(1)
DepenAQnt,yA^ia^lo§.
Role Congruence and productivity
An individual’s performance can be expected to bear some direct
relationship with his role specificity, To the extent the role calls
for diffused functions and is ambiguous the incumbent may be asked to
perform duties which are unrelated to the training and preparation
the incumbent had.
This may result in poor performance parity because
the incumbent does not have necessary preparation and partly because
dissatisfaction and frustration experienced by the worker.
Such con
flicts between perceived functions end those assigned would contri
bute to poor morale in the organisation besides waste of talent.
Therefore we expect the greater the congruence between perceived and
assigned functions, the greater the satisfaction and better the per
formance.
Efficient utilisation of human resources calls for assign
ment of duties and responsibilities in keeping with the talents and
skills of individual workers.
(ii) leadership style and Productivity
The style of leadership including supervisory behaviour will be
related to work performance both directly and indirectly via other
variables in our study such as communication, participation in deci
sion-making, coordination and teat- work, work atmosphere, job satis
faction, morale and commitment.
The direct relationship is established
via dimensions of work facilitation behaviour, goal emphasis and the
human relations aspects of the leadership style.
In tact it appears
tha.t leadership style is a key variable in productivity of the Primary
Health Centre.
Honce, we expect there will be p direct relationship
between three dimensions of leadership as expounded in this study and
productivity of the organization.
The variable will also be directly
related to communication, worker participation in decision-making, team
10
vTork, work' atmosphere, job satisfaction, morale and commitment.
Thus
both diroctlj5' and indirectly this variable seem to influence producti
vity.
cation
(iii)
Communication/programme - related issues and problems in the field
is vital for decision-making and adopting suitable strategies in the
field.
To the extent there is free and frank communication on such
matters the work flow vzill be facilitated.
could hamper decision-making.
Lack of adequate information
Therefore we expect a direct relationship
between communication and productivity.
(iv)
Worker participation in decis_i_Qn-making
Worker participation in decision-making specially in the area of
programme strategies and solutions to field problems can bo expected
to bear a direct positive relationship with performance and producti
vity of the organization.
Such participation helps in getting all
relevant and useful data from persons who have rich field experience.
It provides a sense of recognition and status to the low paid workers
who in fact have a direct responsibility to implement the progranu'aes.
Wo therefore, expect the higher the level of involvement of such workers
in decision-making, the greater the productivity.
(v)
Coordination
Coordination of the activities of the B.H.C, with the activities
and involvementr of other departmental staff, specially that of the
community development and rural welfare should boost the success of
the programmes of health and family planning.
This helps tc reinforce
same educational and motivational processes as are used by the staff of
the Primary Health Centre and it may also enable the staff of other
departments to look at total development of the community rather than
confining
to their own field of special interest.
Coordination with
voluntary organi^^g^ would give a sense of community participation
and thus contribute to the success.
Therefore wo may expect a direct
positive relationship between coordination and productivity.
(vi)
Tcan work
While coorcfe-n^.ti-b^i is from without, team work is from within the
organization.
It is brsed on a sense of joint responsibility of all
members of the staff to programme success.
It generates mutual respect
and acceptance of all disciplines as necessary and their joint effort
as vital to programme success.
Such team work may result in better
solutions to the problems than would be the case when each worker
I
11
tackles it from his/her individual perspective or speciality. Further
such team work would contribute to morale and thus indirectly also help
success of programmes.
Therefore we expect a positive relationship
between team work and productivity.
(vii)
Work atmosphere and_-Commihno_nt
It is obvious that the physical and social circumstances under
which work is carried out are important determinants of performance.
Likewise conmitment and morale are important determinants of perfor
mance.
Therefore we expect a positive relationship between performance
and these two variables.
(viii) Flexibility and. Ri^AUr_?XJke
As indicated earlier, there appears to be more rigidity in the FHC
organization in rules of recruitment, promotion, transfer, administra
tion of economic rewards etc.
factor across PHC units.
However, this is a more or less constant
On the other hand the Medical Officer of the
PHC seems to have considerable freedom in programme execution strate
gies, supervisory style, work facilitation and human relations aspects.
He could also encourage innovative approaches to solution of field
problems, generate team work and provide psychological rewards for
good work.
Thus the question is to what extent the flexible areas of
the system are exploited by him to increase performance.
viour may vary
This beha
across P.H.C. units and needs to be measured, We do not
have any specific hypothesis on rigidity vs flexibility, independent of
Diagramatic representation of the relationship among these variables is
provided on the last page.
7.
Sources of dat~i and methods oi^ da oa collection
The type, of information we require in this study is not likely to be
available in a written form, Therefore most of the information has to be
collected either by interviewing knowledgeable persons or persons who are
affected by the processes we are concerned with, It is assumed that most
of the relevant information can be collected by interviewing the Medical
Officer, the Sanitary Inspector, the Extension Educator and Lady Health
Supervisor...The method of data collection that ismost appropriate for
a given variable has to be adopted.
In otherwords we have to be more
flexible in our data collection procedures specially when we are concerned
with processor variables.
As far as possible interviews will be supple
mented by observation, rating systems and such other procedures.
It is
proposed to spend between 20 to 50 days in each primary health centre to
get as much information as possible and to cross check data obtained
though different sources.
A team of atleast two investigators will study
each primary health center under the supervision of an experienced resear
cher to assure quality of data collection.
—i
12
Under the typology of organizations worked out by Blau and Scott
(1962: 51-54), the Public Health Organization would be considered as
a service type of organization where the primary emphasis is on profes
sional services to the client population.
Therefore, in evaluating the
performance of such an organization it may be useful to consider its
impact on client population besides evaluating it from the point of view
of its members.
Underlying assumption in such an evaluation is that an
organization which is high on the processor variables would have provided
more' satisfactory services than the one that is low on these variables.
Several categories of client (local community) population can ■be consi-
dered here such as leaders, former patients, current patients etc.
A sample of these categories could be interviewed in the respect of
Primary Health Centers that are high or low on processor variables.
8.
Procedure for data analysis
The primarv goal of this study is to measure the eight process varia
bles and examine their relationship to work turned out by the primary
health centers over a three year
period.
Since we are proposing to study
only the lower level units in a complex bureaucratic system, the const
raints imposed on these units from higher level centers are to be consi
dered in evaluating their performance.
From the point of view of analysis vro arc- interested in examining
the strength of relationship of each independent variable to performance.
The idea is to select those processor variables that explain a significant
proportion of variance in performance of the primary health centers for
incarporating into an action programme.
The amount of variance in
the
dependent variable explained by each variable separately and all of them
together will be examined by
correlation and regression analysis.
Since
the variables involved are only few and the number of units of observation
are about thirty five
computer analysis may not be needed.
Using
electronic desk calculators available in the Institute we can analyse
this data.
If however, we are going to cover all P.H.C, units in Tamilnadu.
we have to invest lot .more money than is provided in the attached budge".
Also analysis will have to be done by computer usage.
S.
Timo Schedule for the Study
(a) Designing the study and pretesting of
instruments, including pilot study
4 months
(b) Data collection
8 months
(c) Data analysis & rorort writing
4 months
Total time
16 months
-2
10.
15
Budget estimate
The study of organizational variables is very difficult and
requires people with high competence in behavioural science
research. Preferabl- the study has to be done through teams of
skilled interviewers and observers with some experience in measu
rement of behavioural phenomena. Therefore it is suggested that we
constitute six to eight teams of two investigators each for studying
intensively in P.H.C. units.
A team of two investigators could be
assigned to each P.H.C. and two or three such teams could be super
vised by a competent researcher. Assuming this pattern of staffing for
the study a tentative budget is provided in the Annexure.
5 b
5
MAGIUKl'flC HEFaBSEKT TICU OP THE REI, j.TICNSElP
BETWEEN PROCESS V..",RI.'J3LE .iKE PE35V/21AKCS
Imed^te^VgTiabXe.s^
Background Variables
i
t
t
Training
.J Role congruence of ;
'
workers
; Administrative
J situation
Intervening Variables
Depondent
Variable
} SfC.ll utilisation
!
!
Job satisfaction ]
and morale
J
j
J Leadership style
=4[ of Medical Officer
<1
’
Past
i Experience
i
Personality
type
t
—I..*
•' — J 1
Performance [
’ Communication
’v
Decision--raking J
—
’ Co-ordination
! and Team-work
!
!
P.S. We have to include resource.. utili^aMon as one of the intervening variables if we think
it is different from manpower skill utilization and coordination with other agencies etc.
COMMUNITV HEALTH CtLL
47/1, (First Hoo.) St. Marks rtoad
BAMGAkOrifc - 56G- 001
ALPLIWIX-A
nraiiw*-•.<v-*.- . i»n ■■>
-r:.
SOME SUCfUESI^L ITj^LB LOR INC HITS ION IN Lin AS UR ING- INSTRULiLgT
RQJlE CONGRUENCE
Dimensions
1.
Role as perceived by the supervisor Vs role as perceiby the inc ombent.
2.
Role as perceived by the incombent Vs role as actually
carried out.
3.
Role as perceived by the supervisor Vs role as actually
carried out.
Better than using a checklist which may tap mechanical
responses we could do some depth interviewing with an
interview guide — i.e list of areas/items/quest ions on
which we need to get information. Supposing we are inter-
viewing the Extension Educator
the following questions may
give as relevant information.
(a) A detailed descriptiqn of activities he generally
carried out in the IHC.
(b) His own perception about the expected functions of
an intension Educator.
(c) What he thinks his supervisor’s perception of
Extension Educator1 s functions in a PHC
(d) Whether what is assigned and what he perceives as
his functions congruent or not.
(e) vverej there are some conflicts between his expected
functions and functions assigned to him - if so how
frequent and pervasive were these conflicts.
(f) Performed functions.
Comparable questions can be asked of the Medical Officer
who
is the immediate supervisor of the Extension Educator^
Some method of Scoring and obtaining a numerical score
for this variable has to be worked out.
Leadership Style
As indicated in the design this variable will be
measureci from a three dimensional perspectives- Work facili
tat ion behaviour, Human relations and Goal emphasis.
The following are some of the items or questions that
measure each of the three dimens ionss
V/or k f ac il it at ion
1 . He encourages members to work as a team
2. He makes contact with other departments for the sake of
the members.
J. He stresses the need for new practices.
0
Q
0^.0
4.
5.
6.
7.
8.
9.
He encourages the team members to put forward new ideas.
He has members share in making decisions.
He convenes periodic and regular staff meetings for
planning programme.
He encourages members to express ideas and opinions.
He sees that members have all materials they want for
their work.
tie lets the tectm members do their work in the way they
think best.
10. He provides means for. members to communicate with each
other.
11. He gives advance notice o.
changes.
12. He sees to it that the work of members is coordinated.
13* He provides facilities for interdepartmental coordination.
14. He- is willing to make Changes when necessary.
15. He uses his influence with outsiders in the interest
of his team members.
16. He puts suggestions by the team members into operation*
17. He encourages the use of certain uniform procedures.
18. He gets the approval of his team members on important
matters before going ahead.
19. He lets team members set their own goals.
20. He finds time to visit members at their work spot.
21 . He sees that members who are in need of technical help
are given help.
22. He permits deviation from advance tour program in case
members think it necessary.
23 He maintains definite standards for performance.
24- He permits change of approach to meet new situations.
25- He keeps well informed about the progress of his team.
26. He utilises staff meetings in a way to advance
knowledge about better ways of doing things.
27. He helps team members construetively to think and solve
problems.
28. He assigns members to particular tasks.
29. He insists that everything be done his way.
30. He does not tolerate any member who does not adhere to
departmental instructions strictly.
31. He rejects suggestions for change.
32. He changes duties of members without first talking it
over with them.
33 • He resists changes in routine way of doing things.
34. Ke decides in detail what shall be done and how it
shall be done.
:3s
do al emphasis
1 . He sees to it that members are working to their
capac ity.
2. He emphasizes the quanlity of work.
J. He stresses being ahead of other team members
4. Heenceu£’a&esmembers for greater effort.
5. He talks about as to how much should be done.
6. He emphasizes meeting of deadlines.
7. He encourages slow working members to greater efforts.
8. He uses achievement as the main criteria for evaluating
all his team members.
'
i efforts to greater achievement when
9. He mobilizes team
he finds targets are not being reached.
10. He sets examples by working hard himself.
11. He emphasizes the quality of work.
12. He asks for more than what members can do..
IJ.'He encourages them to put extra efiorts in national
interest.
14. He lets members work at their own speed .
15. He advises members to take it easy.
16. He never cares to review work together.
Human Relations
1. He does personal favours for his team members,
2. He expresses appreciation when members do good work,
3. He defends team members against outside criticism.
4. He invites members to his home.
..
.
•
■■■'■■—I.................... .....
-
-W
5. He is easy to understand.
6. He complements a member on his work in presence of
others.
7. He helps the members of his team with their personal
problems.
that makes
8. He stands up for .his team members even
him unpopular.
9. He sees that a member is rewarded for a job well done,
10. He speaks in public in the name of the team.
11 .He encourages his team to organize social activities.
12. He discusses his personal problems with team members,
13. He reacts favourably to anything members do.
14. He takes the blame when outsiders criticize the work
of center.
15. He gives out where credit is due
16. He tries to keep his team in good standing with those
"in higher authority.
indiv idu<- i.
17. He looks out for the personal welfaz'e
members.
18. He attends social events of his team members.
19. He associates with members regardless of their positions.
-4$
20. He backs up the members on their action.
21 . He criticizes a specific act rather than a person.
22. He makes members feel at
ase when talking to them.
23. He is friendly and approachable.
24. He publicises outstanding work of his team.
25. Ke refuses to compromise a point.
26. He rules with an iron hand.
27. He criticizes poor work.
28. He speaks in a manner not to be questioned.
29. He criticizes members in front of others.
30. He critizes members for small mistakes.
31 . He treat members like cogs in a mechine.
32. He rides the members who make mistakes.
33. He reverses his stand when he meets outside criticism.
34. He blames members when anything goes v/rong.
35. He presents only his own point of view.
36. He draws a definite line between himself and his team
members.
37. He acts without consulting his team members.
38. He pits one member against another.
P.S.
The questions are not arranged in a random way.
Communication- an inventory of items
1.
2.
3.
4.
5.
6.
The extent to 'which each member feels he has the infor
mation he needs to do his job well.
The extent to which each superior(your) and each of his
subordinates have the same understanding as to respon
sibilities, roles? goals, and deadlines.
The extent to which each superior(your? is correctly
informed as to the expectations, reactions, and percep
tions of each of his subordinates and conversely.
The extent to which each superior(your) is correctly
informed of the obstacles, problems and failures of
each of his subordinates in encountering in his work,
the assistence each subordinate finds helpful or of
little value; and the assistance each wishes he could get.
The extent to which members of your organization at all
hisrarchical levels are motivated to communicate fully
and accurately all the important information to all
persons for whom the information is relevant and valuable
and to omit the irrelevant in order to avoid overloading
the communication system.
Upward Communicat ion
a) The extent to which upward communication via line
organization is perceived as adequate.
b) The extent to which upward communication via line
organization is perceived as accurate.
:5 s
c)
<3)
e)
f)
g)
The extent to which there are forces leading to
accurate or distorted information and nature of these
forces.
The extent to which there is a felt need for supple
mentary upward communicat ion system(e.g. suggestion
systems etc.)
How free do you feel to approach your superior and to
communicate with him? Is he friendly and easily
approached?
How well does he listen to you?
To what extent are members of your organization inter
ested in listening to you?
i) Are they (and your superior) interested in
knowing about your problems?
ii) Do they (and your superior) ask your opinions
when a problem comes up which involves your work?
iii) Are they(and your
our superior) interested in sugges
tions?
f
iv) Do they(and ylur superior) values your ideas 9
seek them and lendeavor to use them?
Worker participation in dec is ion-making.
(1) How do members of yoi|r organization feel about the
decision-making proc s as related to programme
priorities, strategic, and handling of field level
problems?
»
(a) To what extend da they feel that decisions
are made at the right level and by the right
people? Are persons involved in decisions
relating to their work?
(b) To what extent do members feel that their
ideas, information, knowledge of processes,
and experiences are being used?
(c) To what extent do members feel that important
problems are recognized and dealt with promptly
and well?
(d) To what extent do they feel that the decision
making process makes full use of all the relevant
information available within or to the organization.
(2) To what extent are the decision makers fully and
correctly aware of problems, particularly those
problems at lower levels of the organization?
1 .
Team work and Group work
To what extent does your organization(and your superior)
holdgroup meetings to make decisions and solve work-related
problems? Are such meetings worthwhile?
(a) Does your organizat ion (and your superior) help each
team or group, including yours, developing skill in
reaching sound solutions?
(b) Does your organ iz at ion (and your superior) help each
teach or group, including yours, develop the skill
in effective interaction and in becoming a well-knite
team rather than developing hostile subfactions?
2.
5.
: 6;
(c) Does your organization (and your superior) use
(
ideas ant solutions «bioh «r6e, and does it
(he) also help each group to apply its solution
Does your organization (and your superior) encourage
working in teams rather than each worker doing his own
job?
(a) If you work in teams who are the people who
constitute such"work^tearns in your or£.anizat ion?
have worked?
(b) How well do you think these teams
such t e am v/ or L?
(c) What are the advantages you find in
How often do you make joint visits to field?
(a)
(k)
For what kind of programmes?
For what reasons?
Co-ordination
Def in it ion
Dor purposes of this study we restrict the work
activities between
co-ordmat
j-uli to
yu joint or collaborative
ordination
the concept of team work
one organization
organ iz at ion and another and reserve
to coordination of activities of specialists within an
organ izat ion.
Co-ordination of activities at the-P.H.C. level could
interdepartmental coordibe studies from the point of view
of activities of the Primary
nation as well as coordination
voluntary organizations
Health Center with those of other
working in a given area.
Krteut ol co-ordinated work can be measured by asklr,;.
ooeollio cpehtlons to eeleotod 1.B.0 BtMl and ale, to
selected stall ol other oceanizations or agencies,
mo extent ol oonoordaoeo in such reporting could
as a test ol reliability ol the ans«ers given m thm, a^ .
Alternatively we/could
/could observe the aotlvitieo ol the P.a.O
■
n
t he inst itut icnalized
-f -F-ir'-o +n
over a specified period oi time to see me
coordination and how often they do
mechanisms they have for
• • , coordination or how successful
really work hard for obtaining
evaluated independently by ^n
they are as reported or e.observation team.
Some quest ionnaire items
Are there other departmfents/^ith whom you corordanate
the work of your organization?
' Yes
No
/~ 7
.c7s
If ’Yes1 which are the depar tme nt s/organ izations with
whom you most frequently or often co-ordinate the work
in health and family planning?(Spec ify)
is such co-ordination desirable from the point of your
own work or organization1 s .product ivity?
How successful (you think) you have been in obtaining
such co-ordinated help from other departmental staff/
organizational staff?
What problems (if any) have you faced in getting such
co-ordinated? (Spec if y)
What is the mechanism you have to obtain such oo-ordination?
Work atmosphere
1. The extent to which members of your organization
feel that the atmosphere of the organization is supportive
and helps each individual achieve and maintain his sense
of personal worth and importance.
2.
The extent to which cooperative attitudes exist.
(a) The degree of confidence and trust among peers,
among the different hierarchical levels, and
among the different organizational units...
(b) The extent to which attitudes toward superiors,
peers, subordinates, and other relevant persons
in organization are favourable.
(c) The. level of peer-group .loyalty (att idues of subor
dinate members of work group toward each other, ie.
peer-group loyality. attitude toward superior, and
attitude and behaviour of superior toward sub
ordinates)
3.
The level of co-operative attitudes. within each unit
of your organization, among units, and among various
parts of the organizat ion, such, as, line and staff,
divisions, departments, and headquarters.
;8 s
On _the Commitment Variable
-1
■■ Tl- MTIwr
■ ■Jr
fW .TWmyWrtl.*nr ACU
If morale is defined not as an individual job
satisfaction but as a property of the group signifying
essentially a sense of identity with the team and its
goals, then it has to be measured in terms of this
feeling of belongingness, identify with group goals and
zeal to work toward group goals etc. Following Yoder
(^970) we may treat morale as evident commitment and
therefore need not distinguish the two in terms of opera
tionalization and measurement.
We have to pay more atten
tion to operationalistat ion and measurement of morale and
conceptually distinguish it from measurement of job
satisfaction at the individual level.
A further important distinction we have to make
is between commitment to an organization or commitment to
a programme,
In terms of success:of family planning is
there going to be a difference if we concentrate on the
one rather than the other dimension? Are they really
distinct and separab Le dimensions? Can an individual
be committed to programmes of an organization but not to
the goals, philosophy, methodology etc. of an organization?
T
’O1
Co-operative attitudes
Wtual acceptance
Identification with
work group including
M.O. Cohesiveness of
group.
Out im ism ab out group
success.
Conviction regarding
group goals.
7-
Men t if ic at ion
with original
goals.
Acceptance of
original Phil,
and methods of
work.
Preference to
stay with the
org an iz a t i on whe n
a alternative
job is available
outside.
Id ent if icat ion
with Family Plan
ing Programme.
Acceptance of F.P
contraceptive
methods .
.Evidence of use
in one ’ s own ..
family (if eligi
ble to do so)
Items under A,B,C above refer to commitment to team?
organization and programme respectively, we may obtain a
total score on commitment Try adding up scores on each
dimension specified above.
'y
:9s
BUDOSI ESlIMkL'L FOR AOtlON-RBSEARCH UNIT
I.
A. For Data Collection
1. Research Officers 12 ® Rs.700/=.
per mensem for 8 months Rs.700+100(D.a) —80'.,'
Rs.800 x 8
=Rs.76,800
2. Research supervisors 3 & Rs.800/=
per mensem for 8 months Rs.800+100(D.A)=900
Rs.900 x 3 --=2700 x8 =Rs.21,6OO
B• For data analysis and report .wrij^in^
1, One Research Supervisor ©
x
per mensem for 4 months Rs.800+100(I).a)-900
Rs.900 x 4
=Rs. 3,600
2. One Statistician feRs »600/=l . ai.f or
4 months Rs . 600+100(1). i.) = 700
, - x 4
:RS . 2,300
0• For.Act ion Tart of the programme
1. One Research Supervisor @Rs.800/=pm.
Rs.21 ,600
for 2 years Rs.800+100(U.A)=900 x 24
2. 'hw Research Officers
Rs.700/=p.m.
Rs.19,200
for 2 years Rs.700+100(D.A)=800 x24
R. One Director of Project for 3 years
©Rs.1050/= in the stale of Rs.1050-50-1200
year = 13,800
Pay and D.A. for I1
II year = 14,-+OO
III year = 15,003
Rs.45,SOO
45,200
Travelling Allowance for Research Staaf
oveFa"heriod of 3 years ©Rs. 10,000 per vear =Pjs.J0,000
=Rs.20,000
III. Of f ic e e otu ip me nt, etc .
11
IV. 31 a t ion a:, -y and Printing
V. Contingencies
=Rs.10,000
-Rs.10,00
Total of I to V = Rs.2,58,800
VI. w/s
VII. Training
Total estimate for Action-Research Unit
---Rs. 10,000
=Rs.10,000
Rs.2,78,800
- w --
"WH-
js?.
i.
.
hi
inn^
ji
mi
■
COMMUNITY HEALTH CELL Con3 H U-U*
■
47/1,(First Floor)St. Marks Road
BANGALORE-560 001
OfSRaT TONAL, R3o3ARC[T IN HS ^LTIl CAR3 DELIVSBY
RraaL NI^kLTII TRalNING, CENTRE,
Dr . R.K. SSTH, D.P Ji., (Calcutta)
D.P.H. (Toronto)
Officer-in-charge, Rural Health Training Centre, NaJ af garh
(Delhi)
Paper presented at Xllth Annual Conference of All India
Association for the Advancement of Helical Education,
Ahmsdabad, dated the 12-14th January, 1973.
The present complex at Najafgarh came into existence in
1937 as a Rural Health unit.
The aims and objectives were to
study and recognise the particular health problems of the area,
to chalk out effective methods to solve them and to utilise as
a Training Centre for personnel from various other institutions.
As a result of the recommendations of the Health Survey
and Development Committe , the Rural Health Unit was converted
into a Primary Health Centre in 1953.
Incidentally, this was
the first Primary Health Centre to be established in the country.
Two more primary health centres having 5 sub-centres under them
were added from 1955 to 1957.
In 1957 this unit was taken
over by the Directorate General of Health Services, Government
of India and redesignated as Rural Health Training Centre.
Since then the Centre has developed as a training-cum-service
The various functions of this Centre are:centre.
1.
2.
3.
Research
Training
Service
SorVico:
To provide integrated health services to an area which
consists of 72 villages with a population of about 135000
saatterad over 432 sq. k.m. is one of the important functions
of this Centre.
The delivery of health care takes place
through the three primary health centres which functions under
the overall supervision and technical control of the Officer-inCharge..
'The staffing pattern of the primary health centre is
The
by no means standard as compared to laid down pattern.
population load per staff member is as bslomD o ct or
Dispenser
Extension Educator
Sanitary Inspector
Public Health Nurse
Lady Health Visitor
Midwife/Trained Dai
1 for every 22,090
tt
45,000
1 it
ii
ii
45,000
1
it
27,000
1 ii
it
27,000
1 ti
ti
13,500
1 ti
ti
ti
6,500
1
Led leal Reliefs
This is designed mainly as an institutional service.
The out-patient clinics give diagnostic and therapeutic services
for minor and moderate ailments.
Facilities are available for
referring severely or chronically ill patients as well as those
suffering from intract ible diseases to the major central
hospitals for investigation and admission.
In most cases it is
possible to arrange for conveyance also.
COMMUNITY HEALTH CELL Corn H =1-11*
47/1,(First FloorJSt. Marks Road
BANGALORE-560 001
OFBRATIONilL xRE SEARCH III HE ALTH CARE DELIVERY ■
RLRhL HEALTH TRAINING CENTRE, N^AFGARH
Dr. R.K. SETH, D .P.H ., (Calcutta)
D.P.H. (Toronto)
Officer-in-charge, Rural Health Training Centre, Najafgarh
(Delhi)
Paper presented at Xllth Annual Conference of All India
Association for the Advancement of itodical Education,
Ahmedabad, dated the 12-14th January, 1973.
The present complex at Najafgarh came into existence in
1937 as a Rural Health Unit.
The aims and objectives were to
study and recognise the particular health problems of the area,
to chalk out effective methods to solve them and to utilise as
a Training Centre for personnel from various other institutions.
As a result of the recommendations of the Health Survey
and Development committe , the Rural Health Unit was converted
into a Primary Health Centre in 1953.
Incidentally,
Incidentally this was
the first Primary H alth Centre to be established in the country.
Two more primary health centres having 5 sub-centres under them
were added frcm 1955 to 1957.
In 1957 this unit was taken
over by the Directorate General of Health Services, Government
of India and redesignated as Rural Health Training Centre.
Since then the Centre has developed as a training-cum-service
centre.
Tho various functions of this Contra ares-
1.
2.
3.
Resear ch
Training
Service
lOrVics:
To provide Integrated health services to an area which
consists of 72 villages with a populatich of about 135000
scattered over 432 sq. k.m. is one of the important functions
of this Centre.
The delivery of health care takes place
through the three primary health centres which functions under
the overall supervision and technical control of the Officer-inThe staffing pattern of the primary health centre is
Charge.
The
bjr no means standard as compared to laid down pattern,
population load per staff member is as balow:-
D o ct or
Dispenser
Extension Educator
Sanitary Inspector
public Health Nurse
Lady Health Visitor
E id w if e /Tr a ine d D a i
1 for every 22,000
It
45,000
1 It
tl
II
45,000
1
It
II
27,000
1
It
27,000
1 tl
II
13,500
1 It
It
II
6,500
1
lied leal Relief;
This is designed mainly as an Institutional service.
The out-patient clinics give diagnostic and therapeutic services
for minor and moderate ailments.
Facilities are available for
referring severely or chronically ill pat lent s_ as well as those
suffering from intract ible diseases to the major central
hospitals for Investigation and admission.
In most cases it is
possible to arrange for conveyance also.
a
2 -
The demand fer curative services is constantly ©n the
increase as is indicated in table N©.1 belowsTable
N©. 1
Attendance
XSiar
Total attendance
1968
1969
1970
1971
154283
171726
175744
185724
The above figures indicate that during the last few
years CH) attendance is sharply rising in the primary health
centres.
Consequent to such a heavy rush in the OH) the
primary health centre doctor is mostly confined to the OH)
as
in providing treatment for minor ailments.
As such he does
not get sufficient time to devote to field duties which is one
of the most important components of his responsibilities,
Estimated distribution of a doctor's time in a primary health
centre is given below: (weekly) .
63.3^
20.3"
16.4^
OPD
Office work Field Visits -
Because cf the heavy rush in the OH) the doctor is not
"
■" ' j
According
in a position to do justice to all the
patients.
to a study conducted
. . at. primary
.
.health centre,
X. _
Najafgarh the
time devoted by a doctor in examining and diagnosing the diease
of a patient is shown belowsTable No. II
Time spent by a doctor with a patient
Time spent
minute
1 minute
2 minutes
3 minutes
34 minutes
of patients
10.4
50.0
37.2
0.1
2.3
The patients seeking relief have also to spend a lot
time
after
having doctor's consultation and getting medicines etc.
of
Though the throws strain on the limited resources
cf the Centre, it is encouraging to note that the public is
drawn more and more towards the primary health centre for
curativs facilities which results in providng opportunities of
developing contacts and confidence between the staff and the
people.
A study conducted on the distance of the villages
from the health centre for utilisation of its services shewed
that the attendance varies inversely with the distance i.e.,
people living nearer the health centre avail of more facilities
that these at the periphery.
J
3
Table
No.
Ill
- Distance wise
O.P.D.
pistance (in mile s)
of OPp attendance
1
mile
1- 2 miles
2- 3 miles
3- 4 miles
4- 5 miles
5+ miles
61.8
18.5
3.5
9.7
1.5
5.0
about 80.00 per cent of the OfD patients in the primary
health centres were from the villages situated within a radius of
2 miles. age-wise distribution of the OfD patients during the
last few years is shown belcwsTabla No. IV
Age-wis?
Distribution
<ige group (in years)
0
1
5
15
35
54+
1
4
14
34
54
1969
.971
11.83
16.64
23.18
24.94
15.20
8.11
16.95
16.16
20.11
23.47
16.81
6.60
Maximum jnumber
"
of the patients attending the primary
health centres came from the age group of 5-14 years and 15-34
years which was followed by other age groups.
Najafgarh which was once predominantly rural is gradually
developing into an urbanised area.
But so far appreciable change’
has been noticed in the general morbidity pattern. Digestive,
respiratory and parasitic and skin diseases still occupy first few
Places in the morbidity table.
Table
No, V
Morbidity pattern
1.
2.
(OfD Patients)
Infective and parasitic diseases
alleggic, endocrine system , metabolic and
nutritional diseases
3. Diseases of blood and blood forming organs
4. Diseases of nervous system and sense organs
5. Diseases of circulatory system
6. Diseases of respiratory system
7. Diseases of digestive system
8. Diseases of urinary system
9. Diseases of reproductive system
10. Deliveries and complications of pregnancy
child birth and puerperium
11. Diseases of bones, joints and muscles
12. Diseases of the skin & cellular tissue
13. symptoms of senility and ill defined
conditions
14. Accidents, poisoning and violence
1968
1971
8.0
4.2
9.6
•0.1
10.1
0.5
21.4
17.0
1.5
0.6
6.17
0.18
7.77
0.27
18.67
19.39
1.04
0.96
0.8
3.4
16.3
1.44
6.47
13.75
0.1
10.1
8.21
11.4
Besides institutionalised medical relief medical relief
____
_ ___ _
rp p <“-i
at the peripheral level is also provided by the
subeentres.
maternity and child health staff’while visiting villages^on their
routine visits are also expected to give symptomatic treatment
■
■ 87888
’
** bb<.8b.
;'8b^
88b^|g
IM iM
Qtt
I
4
ill
8g1 ■ .
r
"f
Jlyont..; ..hich they cons across in ths
88.11ages.
For this purpose they hold clinics after finishing
tillage s,
|8 ■ dcnicillary visit.
As such it has been made possible to
“fcver the minor ailments and follow up of certain important
iomm uni cable diseases like tuberculosis etc.
This type of
iomicillary medical relief service helps not only in making
Available medical relief at the peripheral level thus reducing
fork ____
load --in OFD of a primary health centre but also in winning
il
B7.b8;8f’ -■ -cnfidence of rural communities for establishing fruitful
relationship
with them. It also contributes in
SsSS!jerking
.............
joftening their resistance and ensures their active participation
k|m jor new public health programmes which are introduced from time
8 time.
i1,1 ’i
11
,
iwitlW
77'87'7
Prior to 1966 the patients requiring specialist's
8b'87|!|r©atoent or investigations were referred to city hospital at a
:|l|l'“
of about 17 miles from the primary health centre.
:• was, hov;ever? experienced that because of lack of adequate
Tg
^transport facilities, costly procedure involved in staying in
the city hospital coupled with the lack of less confidence of
...
■7,7 - the rural folk in hospital services and the difficulty of having
direct contact with different environments, the rural ±clk haci
■ been hesitating to be referred te a city hospital.
keeping this
B ■
■attitude f the villagers in view the system ci making available
' 'l l‘'14
services right at the primary health centre level
''>M'!<777™ ;■
was thought of and '-he idea ultimately materialised in
■1966.
since 1966 specialists from the Safdarjang Hospital
■have been visiting primary health centre. Najafgarh and Palam
twice a week.
mbM
■
■■
■■■
■M
a
|H8Bt
i|l!1ijlili7'1
"1
Like-wise for reasons enumerated above, it was further
|observed that patients from the surrounding villages even show
1 1 reluctance to get admitted as inpatients ih the primary health
centre of area. They prefer to be. treated indigenously rather
than take treatment from a primary health centre.
To find out
I the attitude of the villagers
towards
sickness and .treatment
o
..._
‘j
!' the villagers were interviewed and it was revealed that they give
more importance to their work in the field and less to their
health.
sssBM I
'mIlliM™
Sit!
f
' ' 7'7'Ml
'''it1;;,'
il' lf7l! i|l |1.
I
11™
■f
No. VI
Patients attended by Spa, deal ists
Tabla
Year
bed leal
ye
1'JT
Paediatrics
Surgical
Total
1369
I^KsnSgi 1970
1971
936
818
898
1135
1017
1311
110
976
1183
236
89
509
437
560
2926
3337
3952
8 8<8 . '
; ■ "JI
.18,8 '‘te,;;;?
88'7, 'b l®
Majority of the patients are provided medical relief
through the OPd cr MI
Mi clinics but some patients who need
continuous medical car?, are admitted in the indoor wing of two
primary health centres which have a combined strength of 26 bads.
Due to the limited bed strength available with the centres it was
found that only 0.9 per cent of those attending the OJD could
be admitted in the indoor.
Average number of patients per day
varied from 9.2 to 10.
While the average length of stay per
■. - patient was 6 days, bed occupancy ratio is also quite high
Mill
• !
MflB
■■■■
'|l|'l'!l'i|l
I
II
I
'v' I
(S£.O>6 ) .
f jtsiilT' I
iiH1
lllll
1 III .'.■.'.'A1.7'87''
777' 7.'
77,7.7
'<' '7' 77
'771] j ';11,' i",
■s
liil ill \
11
|||W
Illi
fell
It is noted that out of the total indoor admission
56.6^ came from villages within a radius of 1 mile whereas
76.1$ of the total patients came from villages lying within a
radius of 3 milos fyom the centre.
Morbidity pattern of
inpatients is shown below:
Table No. VII
5 -
Table No. VII
Morbidity pattern of inpatients
1.
2.
3.
4.
5.
infective, parasitic
Deliveries
Respirat ory
Digestive
Others
30.4
21.2
18.0
11.7
18.7
In short, medical relief still continues to be a major
public health problems, though it is desired very often that it
should occupy a less time of a medical officer In a primary
health centre in comparison to the preventive and promotive
programmes. For minor ailments it has been found from observations
and studies that the presence of doctor is not so essential in
treating these cases and could very well be looked after by an
experienced public health nurse or compounder.
This will enable
the doctor to devote more time to the field work.
Since the
existing facilities at the disposal of a primary health centre
are not enough to meet the demands of the community .the doctor
is expected to guide the community in utilising their own
resources for health improvement programme.
It appears that a
satisfactory medical care programme of curative facilities is
very much necessary at the present time to make a proper impact
on the public whose confidence in public health workers can be
built by demonstrating and providing that in need he will be
properly looke after.
M.C.I1. Services:
The maternal and child health services have necessarily
to be institutional and domiciliary.
This has been organised
in such a way that each normal antenatal case attends at least one? in
fundamental
each trimester for check up by the mddical officer. The
---- -------objective of the MCII services is to provide a total welfare care.
The working objectives of the maternal services as
have been envisaged are:(1)
That every expectant mother is registered as.early as
possible and not later than 20 weeks.
She is given
necessary medical attention, health supervision at
regular periods which would result in safe delivery and birth
of a healthy child.
(2)
Reduction of prematurity through
(3)
Making domiciliary midwifery safe through training
and supervision of indigenous dais.
proper ante-natal care.
The Ob.iectives of Child Health Services are:
(1)
(2)
(3)
(4)
Complete medical care
Pr ote ct ive immunizat ion
Health Supervision of pre-school children
Prevention of nutritional disorders.
Maternal and child health services operate from three
subcantres and II dai centres.
main LCH centres, 5 subcentres
The staff
consist of 3 lady doctors,, 5 public health nurse?, 10 lady
health visitors and 21 midwives trained dais who are directly
programme has been
involved in this programme.
LFamily. planning
.
The
worker
ratio with
fully integrated with the lid-I services,
the population is shown below;
6 -
One lady doctor for 45,000 population
Ore public health nurse for 27,000 population
One lady health visitor for 13,500 population
One midwife/trained dai for 6,500 population.
Ante-natal service;
Aimed at early detection and total care of pregnant
women from the time pregnancy is correctly diagnosed till its
termination.
.The following table reveals the analysis of
registration.
fable No, VIII
Period of registration (in weeks)
c
Year
10-20 weeks
21-28 weeks
29-40 weeks
Total
1S68
1969
1970
1971
63.0
62.3
55.0
60.2
29.0
22.1
8.0
15.6
100.0
100.0
100.0
100.0
45.0
39.8
It would appear that 58.0% antenatal cases in the area
weeks of pregnancy and approximately 88.0%
are registered by
received care by 28 weeks of pregnancy,
Registration is done
by midwife/trained dais, 85 indigenous dais (80.00% of whom have
received orientation training) have been provided delivery kits
and are also conducting cases in collaboration with the field
staff. Though majority of the cases are registered in their
respective villages, some women residing in the nearby villages
report directly in the clinics for registration. As was observed
in general OPD, the antenatal mothers too find it difficult to
attend the clinics from long distances.
In the absence of any
complaint, they do not realise the need for a check up by the
medical officer.
In fact even during the home visiting of lady
health visitor or midwife many of the pregnant mothers-try to
evade the issue and feel shy to get examined.
Health education
and persuation seems to be necessary to impress on the mothers
that ths antenatal examination is necessary from the preventive
aspect.
Table No. IK
t nte-n3^.;.^ c^-^ri--c attendance
a
Distance from
centre (in miles)
No. of mothers
registered
Less than 1 mile
1- 2 miles
2- 3 miles
3- 4 miles
4 - 5 miles
5 +
378
436
295
205
121
57
No. of mothers attending
clinics at least onoa
No.
359
97.9
192
44.0
34
11.3
22
11.0
29
24.0
8
14.0
Since mothers find it difficult to walk up to tha
centres it may be necessary and possible for a mobile team to
and
include examination of pregnant mothers in their homes
spars them ths strain of coming to the centre,
The lady health
visitor herself should be able to screen cases during her domiciliary
visits and keep complicated cases for examination by the doctor
at the time of her visit to the village.
Summary:
1. Thu attendance in the out-patients department of the '
primary health centres is showing an upward trend indicating an
increasing demand for curative services.
7 -
?*
Ths Primary health centre doctors do not get sufficient
time to perform field duties as most of his time (63.3$) is
5hsl.Ofl■)•. On tha ce>ntrary it has always been emphasised
that whe doctor should devote maximum time in the field to
carry out his operational responsibilities for which he needs
managerial capabilities relating particularly to efficient use
of resources (men, building, equipment, drugs, supplied, transport 5
indenting - stocking etc.) record keeping communication, planning,
coordination and supervisory functions.
Due to the heavy rush
in the CFD the doctor in 60.4$ cases is able to devote only
thirty seconds to one minute in examining and diagnosing the
diseases of a patient.
3.
About 93.5$ of the OPD patients in the primary health
centres are from the villages situated within a radius of 4 miles.
Out of this 61.8$ are from within one mile radius, (This finding
is similar to Pondichery (Datta and Kale), Andhra (Griffith)
and Uttar Pradesh findings where 94.10$ and 87.0$ per cent cases
come down from a radius of 3 miles.
4.
Attendance from children upto 14 years was 53.22 of
the total attendance.
This finding agrees with the observations
of
Study where attendance of children from the above age
groups was round to 55.0 per cant. There appears to be a slight
difference when cempared with the findings of other studies where
the children upt© the age of 14 years was found to be 47.4$
(Pondicherry), 42.0$ in Andhra and 40.0$ in Uttar Pradesh.
5.
Morbidity pattern of OPD patients at Naj afgarh indicates
that diseases of digestive . system (19.99$) respiratory system
(18.67), skin 13.75$) and Cellular system occupy morbidity table.
The morbidity pattern shows some similarity with the disease
Pattern as observed at Singur 'where also 21.4$, 19.3$ and 14.3$
OH) patients were found to be suffering from diseases of digestive
and respiratory system and of skin and cellular tissues respectively.
Still, dissamilarities are observed with regard to parasitic
infections and accidents and violence,
The compar itlvely
statement is shown:
Sing ur
Ml af garb
(1)
(2)
Accidents, poisoning and violence
Parasitic and other infections
11.4
4.2
4.7
19.0
6.
21.2$ of admissions were due to obstetric. Average
number of cases per day in a primary health centre varies from
The average length of stay per patient was six days.
9.2 to 10.
In Pondichery the average duration of stay in the centre was
Naj afgarh is 89.0$.
found to be 3 days.
.Bed’ occupancy
. ratio'at
'
■ ■
I
7.
58.0$ ante-natal cases .in the area are registered by
20 weeks of pregnancy and approximately 88.0$ cases receive
care by 28 weeks of pregnancy.
8.
Visit to ante-natal clinics varies inversely with the
distance.
97.9$ mothers living within a mile from centre
visited the clinic at least ©nee during their antenatal period,
whereas only 14.0$ cases came t© such clinics who were living
at a distance of more than 5 miles.
9.
10. 44.9 per cent deliveries are conducted by centre
midwives as compared t© Pondichery study which disclosed that
only 16.8 per cent deliveries were conducted by the centre
midwives.
The Registrar Central of India (1969) during their
8 -
half yearly sample registration of births and deaths during
1966-67 reported that 8.20$ of the birth in the rural areas
are attended by village midwives or elderly women in the family
or neighbourhood and only 11.0 per cent by trained personnel.
AS such the Najafgarh study shows th at staff at Najagarh is
covering largo number of deliveries.
11.
Of the total village indigenous dais practising
midwifery in the villages 80.0$ have received orientation
training to equip themselves with scientific and asptic
skill in midwifery and post-natal care and have been supplied with
midwifery kit with the previsions of refill.
Deliveries ar?
conducted by these dais with latest knowledge and thus reducing
the number of tetanus c-.ses to nil.
12.
Due to the improved KCH services health hazards
associated with child birth and early infancy have considerably
been brought down as shown by the declining trend in birth
rata, infant death rate/maternal mortality rate and crude
death rate.
It is found that on an average the infant received
8-9 visits in home and 2.5 visits at the clinic.
The toddler
receives on an average 6 visits.
Like all other rural area of the country, bacterial
and parastic diseases still flourish in the rural areas of
Najafgarh, the reasons being due to low level of sanitation
prevailing in the area.
Gastro-intestinal diseases like
Diarrhoea, dysentery are still prominent to some extent more
specially during summer months.
Enteric fever is present in
endemic form and round the year.
Parasitic infestation rate
varies from 30-35$ among the villages.
However, some oi the
important communicable diseases like small-pox, diptheria have
been completely eradicated from the area.
bibliography
1.
Aggarwal R.D.: Current Demographic Situation Centre Calling, Oct. 1972
2.
Datta S.P. and Kale R.V.: An Operational Research
Study in Primary Medical Care in Pondichery,
Indian Journal of Preventive & Social Medicine,
September, 1969.
3.
"-I-J Final Report on Public Health Programme
Griffith ID.H.S.:
Andhra Pradesh, WtlO/SEA/fHA/30, 1963.
4.
Mc-Phail J.E.B. Wilson E.E.I. Eckersley L.W.: A study
on the working of primary Health Centres in Uttar Pradesh
(India) WHO/SEA/RH/14/1963.
5.
Mehta D.C.: Out Patient Statistic from Ahmedabad Rural
District - SEA/VHS/61/0ctober, 1965.
6.
Report on Health Survey & Planning Committee, Man ger of
Publications, New Delhi, 1962.
7.
8.
RoyP.C., Chawala R & Bhandari Vinod; Time and Motion
Study of patients in O.P.D. of a Primary Health Centre,
Maharashtra Medical Journal, September, 19/2.
Rao v N and Sen P.C. - Singur Health Centre - Its
achievements and Lessons, All India institute ox hygiene
& Public Health, Calcutta - 1969.
Con) h c|4'l-
CONltAdN'1^7
DI. T Lx Gi/lMUIuTX HULTH 7 xiU~
paries ftoad
A
IN INDIA
Thisprsjeatz list ximsmmpimhixxl
Andhra Pradesh
1. CSI Victoria Hospital,Didhpalli,Dlst.NiKamabad 503175.- is a few
hours bus journey north of Hyderabad airport and railway junction. •
They emphasise MCI! and Leprosy and Care for 21,000 po ulation.
p
Directori Dr.L.M.Hogerzeil.
This hospital is testing a one shot treatment ilifampicin for
leprosy and has a atedical insurance scheme for villages.
2. CSI Ho8pitaltJaaalaaadugutDist.Cuddapeh,A.P. does not have a
donieilliury prograsne but they do 2000 tubectouies yearly and xun
a nutrition rehabilitation unit.(contact person ia Or.G. rthur oamuel.
3. Anantpur: Rayalaseeaa development Trust is directed by Tr.Vincent
Perrer on the edgue of the twon ISO miles north of Ban@ilore and
300 miles south of Hyderabad on the main highway.
This project, started 1975 employs doctors in vill&gee.There is also
tremendous activity in other community development works especially
in water development. Dr.Titaus is contact person for the oonainity
health work. 14 clinica were running each with a doctor,AL .j and
ayah by early 1976, thus serving basic health care to 70,000
population,namely nutrition and immunisation for under fives,safe
water supply and care of mothers and illness care.
4. Hhiladelphia leprosy Hospital,Salur,Dlst.Srilcakulaa,AP(co:. tact
person- Dr.';.n.*hangaraj,Hed.Supdt.)
Also tney have started a comprehensive scheme for some 20,000 popele
at Pruvathipuram some 20 miles from the hospital.
lalur is several hours by ear from the airport at Viehakapatma.
5. Indo-Dutoh Project for child welfare,6-3-805,Somajiguda,Hyderabad.
Bihar
Brothers to -^11 Men International,r.O.Bunladganj,Gaya 823003 has a
health programme *x run by Dr.G Pals which by 1974 with resident
AfiUs serving 20,000 people. There is also literacy and agricultural
extension work. This place is some hairs south of Patna by bus.
Delhi
Community Health Dept.Holy Family HoOpital,Gkhla,Hew Delhi
(Contact pereon-Sr.Anne de Sousa)
This programme stresses MCH and nutrition and hae lately tried to
reduce costs by using village women as health workers.Foliation
served is about 20,000.
Himachal Pradesh
Wlllingdon I!oepital,Manall,DiBt.«ulu,H.P. During 1976 Dr.Surinder
Kaul is caring for 900 villages in scattered haslets in this
mountainous area using 5 village hoallh workers.
In October thia place is reached by plane to Kulu then an hour by
bus.Normally snow ins blocks thetalley from Nov.to March and it fe
in summer an all day bus journey from Qiandigarh or the railhead at
Kalka or Hopar where a bus can also be obtained are reached by
overni^it train Kalb* mall,or Himtoal Express to Hopar.
..2/-
I
- 2 -
Karnataka
Mallur Health Cooperative,St.Johnes Med.College,Bangalore. Bist.Kolar,
Karnataka is 35 alles from Bangalore off the Hyderabad road(If visiting
Anantpur in A.P. this is on the way) Contact person isBr.Iiavi Narayan
of Jhzev.iedicine,St.Johns* Med.College,Bangalore.
'.allur ri relies on a cess on ailk produced to finance the health
scheme,V.Mailur is not poor.Village level workers will be increasingly
used in future to reduce costs*
Population served is around 4»000 in 5 villages and services are
Capprehensive.Bangalore has an airport.
C.L.I.Hospital Bangalore takes care of a slua population at hherrif
Gardens(Supdt.Br.BenJaain Isaac).
Baptist Hospital,Hebbal,Bangalore has a snail village health progratnsie
on the edge of the city on the raid to Hyderabad.
St.Martha’s Hospital Bangalore take care of a village on the edge of
the city.
Kaahair.
OKI JBt! Hospital,Anantnag,Kashmir is an hr.or so by bus froo Srimger
airport. A village health at steieae covertin; 5000 people in villages and
using 9 village health workers was to start in 197b.Contact person is
Br.M.Xaview,Medical Supdt. or Miss Grace Butt,PHN.
This area is a purdah area, being a conservative Muslim area.The hospital
trains xuishmir girls as AliMs which was in 1975 the only such school in
the State outside the capital.
??a.dhya grade dx
Padhar Hospital,village Padhnr,2iat.Betul,Mr-Supdt.I)r.C."oss Surgeon.
l>r.V.Choudhrie,incharge con unity health,Dr.Veronica oss. This hospital
is Hqrs for the State VilA and its travelling Secretary. The hospital
is 120 miles north of Nagpur and airport and is reached from Nagpur by but
Br.C.^088 through a Water -Gevelopment organisation in Betul has sunk
400 wells.Dr.V.Moss plans a village health programme to serve Ghond
tribals who have high child mortality. Population served will be 36,000
work to start in 1976.
Christian II os pi tai,Chat tanpur, via Harpalpur.a.P.
Maharashtra
1. Dr.P.U*Shah(Hes.10 Suruohi Nariman Point,Bombay 400021) is Prof.of
Pedintrices at Grant Med.College Bombay Central. He has 2 projects
wnich he visits each week in Bist.Thana, 90 to .north of Bombay.
a) Pnlgpar older
backed by WHO
b) Kasa
newer
backed by CASE
Both these projects stress MCH and nutrition nd utilise part-time villagt
women supervised by AN Is of the nearest primary he<a centre.a full day
is ne ded for one project and visitors without permission will not be
entertained.The work is well documented and many papers have been
published.
.3/-
- 3 dr; .
. . a abeile rule nt Co^ ?reser;: ive -ural ••e.reta .reject,
... uwedreiat. -hned:-armynr, wnrusp tra. fhis is rc.-ched oy ovemiyht
train f ror v^o-ibay-doub- .y 'a/reh • xyres- -^ettlny ii to
xedmnxr
arrivi y renednwar 8 an. win project c-iwot be visited with out prior
u ruval fn.-'r drs. role, ...x t.vv n-\ve uatAy visitors -x. d ■•iccoudatioa
is limited*
fain .-royra we u^es village uealt workers(vilL;ge woxien; backed^by
a mobile tenw of
.renedicals.xnis reject -was writtin up in dv s
.‘e-ith by the People published 1j?5»
Integrated e atsi services proiectre'ir. ’• ev. rearitre,Jir. j,
bisngli, viiarveh tra is reached by overnight ’.xhalax'ai express
iron no?:hay•'.Director is -^r.^-ric aam» future of tais project beyond
’76 is uncertain •Direc tor of the entii'e centre is -'r .^-•aoluatkar.
fiiC project served 216,000 people us-ir/, re's .-.
catrolliug 2
prl ’ ry ae 1th ce /.re:
was well deciuented.
V. Jkolcawde,
i ouadatiw for ra-'-e/wch la Jou unity e ■ L
-.r.,
ha half hour
f.L. 4.ur)h;t•ioi k , hxrashtra is reached x.\.
.. icrl bui-i journey
lunch fro-x Ycrr wh rf .uxbay to ^waa are t-, >
to
ndwa. re.or
' ' ■ i :: to vicit it- necexzxry*
’fhis preset nerves 30,COO po ulitio^ wh ewfLcya yo:ie 3C'
villwc ae id* ..-xxaxej ,backed, by a doctor aid social vortex*, ontact
pcrsoris are r
re. loke iikcrjO’ .-Vxey h ve studied the
effectivvuesr of ¥/'■. b for illness.
ere 'y.i/.-'- ShMaitl . ret?/.-wii: ,rew.--- a
Director ^o^,.rciiensive exitH u re
ro ;ect, 'iss tori
: os p it a 1, P0 Pach o d, B i;: t. * ire n y ' v* c,
;. •. •- • r 11 r' .
Urisge
. 1,-0-i al ba-, l-.a, . balpW»0rl /
-cd by
1. •
a.
'.iss arilyn :iil£ • •■■'• or r/..e
:a sa*
~ c iiv- for dt50-0 populitloa !.u-.■■.
illiterate
.- ic t ,? ersai • • 2i\qj
liou£h remote tuis is or;c of kne ac > vxll
Till
Cprotpr<iXis 1;. a b. ;ine prone rea.
•
a
■.. .;r,<or\<At
, ( vi. • .,)
2. vhrij-th ; • a:
, un jab
t« Dej
Je Kinity eMei tet(Siri'Sti n e< .
i4Ud22i,:.ri.-- rof«o Oir«r-is ^-•Harh-.ns Dhillon.
fojpt.
-a\\ •: V’-b,. r-'VJ'J 5'>b0'a X
• 1<’
' - • @4ty
in lie rur-u ..na.x, scaff be; u. entirely provided by 0'.0 using
i.-tern doctors and
. ■ fhc honf; vi:
ski Lin ox iue K’ir; cs
in ttiia pre
■. e we very ,,ood« I .xuni: ■-*1 .-i; xn : lil.,' planning
are etwwed •Doca mi. t .21 r> ic ••oof*
b.c tust.M Gynec(;roi\.3.nowie) runs sev wl : me 1 under fives
clinics mx x bia .post oartwi mropr .-.•rne • dne ort'j ^rtu~sE pro^r tn.
J C'-rc to 50,000
l\-e lost x.rx.i"?
-r-i ■ o oi* tn is aept*;’ivw
:K‘hl
Olt.7 and
people in
u.
v- of Gulch-wan t.>lt
i.. ••'Ob- .-a of
sere w:: ;or “•■■.-1 lv
\. ..... tuc out mi tic: V:
in -> >■ U
I <. •
dos It 1; . iw 1-1 xf re. .rly 2 -t ■
Docanest tb. 1;
icd.
2. director,Jo.xxunix,
e 1th, ac ooert :’Oi-pit•■ l,--n •-rival,
-wire .re .t- ur* ’'ox. reet v r.; c? >rw* . xberoi. bi is px.-ce is rep-ched
by full r -y bus frc-'i bubir v or by ov wi it ronvrer ial.die
prs.’r-.. •-e X'-r -■ well docmexte^ i'rmnin tic-i. -wren -.
reir.f
staff > oi!
out daily Iron tut hospital. ’ m-.x* flv< clJ-.'ics re run
- 4 NOU
1. nutrition 'dahabilitation Centre and village Child Care Centres
Lr.A.Vonkataswany, Nutrition Rehabilitation Centre.Oovt.brskine Hosp,
iladurai.xiiis is a reference centre for Vit.A deficiency blindness
prevention & they have 2000 children with severe malnutrition being
fed in village feeding centres, with the help of balasevikas. Dr.K.A.
Kri8hnaaurthy,Prof .Of Ped.has a strong cotariunity eaphasis.
2. Dr.Kottar Social Service Society c/o Bishops House PB Bo.17
Uagercoil 629001 Kanya Kuaari Diet. This project gives some MCH
care.There is a huge CRS feeding progrt'm® with 30,000 beneficiaries
using hundres of village girls.
3. Chrisfellowship Hosp.centre in v*9dda^atraB,hist.Madurai
^S?harien>whoCis &0past S-esidei’t^of^Al) They train community
health guides.
4. Deenbandu ifedical Mission,n.R.Pet,631303.hist.Chingleput,Tl«
reachable by a few hrs.by bus. This aission has been doing
coaiaunity work for over 20 yrs.Dr.Prera John MPH has recently
written 1975 a new project proposal to serve 20,000 with special
attention to the poorest
pcziz Z 40$ of the people using village level
llage midwives.
volunteers and village
aidwives.
CSI nHospital,Woriur
irs.Stejiien
5» Cox
vcjox uix f h uixux near Tiruchirspalli,">updt.Ur.
- ---------" ' S
supervises AWa resident in nearby village.A email but good
programme.Ktchen gardens are emphasized.
T1 wi ph Its pal 11 ia an airport.-'oath of Madras,, oriur is only a
few miles from the airport.
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- 2 I
oJ-' VM ft k - rz=vo»Q>i -k.
SCHEME OF ’MINI FAMILY WELFARE CENTRES’ aS A
MODEL UNDFr INNOVATIVE' SCHEME OF GRANT IN~“7Td
ASSISTANCE”T0 VOLUNTA^Y ORGaNTSaTIlNS FOR PROMOTION
Cono H o,
lf mch, TMMuWTs7rroN~r~WLr~FAMTTini7URiM7--- -—
OBJLCTIVE
The basic approach of the model is to establish Mini Family
Welfare Centres to promote MCH, Immunisation of Family Welfare Pro-
gramme amongst the section of populationi resistant of family welfare
programme and having high birth rates,
Th ■- s will be applicable to
town and city upt o a population of 1,00,000 and rural areas.
Preference under the scheme will be such districts which have been identif ied as lowCPR and high birth rates (Annexure-I).
s»
2. The objective of the scheme will be entirely motivational to
create a link between the infrastructure of Health and Family Wel
fare facilities and the community to promote responsible and healthy
motherhood and small family norm.
3. The salient features of the scheme ares-
3.1 The Scheme of Mini Family Welfare Centre will be operative
amongst the population group resistant to Family Welfare programme.
For urban areas, it will be limited to slum and unauthorised areas,
in towns with population ranging upto one lakh.
In the rural areas,
the scheme will be restricted to areas; having low CPR and high
birth rate.
3.2 The objectives of the scheme will be entirely motivational
to serve as a link between the infrastructure of Primary Health Cen
tres, Sub-Divisional Hospitals and Family Welfare Centres, Voluntary
Organisation Hospitals/Clinics and the c"
unity.
3.3 The population to be covered in urban areas will be 25,000
divided into five field units of 5,000 each,
In rural areas, the
population to be served by each unit be 15,000 consisting of five
field units of 3,000 each.
3.4 Structure:-
Each project will consist Mini Family Welfare
Centre (MFWC) with a unit co-ordinator as Inchrrge.
Each Mini Family
Welfare cennre will have five units. In each field unit there will be
five Sahelies to be selected from Anganwadi workers, Balwadi teachers
or any instructor under other child survival schemes from the operalive units under those schemes located in the area of operation of
these project.. Th6 lady workers from community can also be appointed
as Saheli (i) if above named workers are not Willing (ii) due to
special requirement of the segment of population to be covered.
0ne
of the saheli worker will be selected os group leader .after ascertain
ing the leadership quality and watching their qork for about three
months.
. .2
4. This scheme is both for urban and rural areas. Through this
model, attempt is to reach the grass root levels and create awareness
in the community served in a
phased manner step by step from the
very beginning of family formation i.c. marriage.
In gradual and
step by step method the MCH and family planning is generated as the
family do steps keeping a.continuous touch with the bride developing
into young mother.
She is -also trained in the art of motherhood by
Voluntary worker
Voluntary
worker known as 'Saheli'in this
This trained mother becomes an agency herself for passing
the grass root level*
model.
these traits to the new brides in her family and those in close
proximity.
Thus gradually the MCH L Family Welfare motivation would
progress in a chain like manner and in our course the worker will
have to concentrate on lesser number,of families and
and contact with
trained mother' would be of maintenance centre.
5. The Mini Family Welfare Centre
The Mini Family Welfare Centre will have 5-field units and
each unit will serve a population of 3,000 in ruril areas and a
population of 5,000 in urban areas,
The folrowing conditions have
to be fulfilled:(1) The Mini Family Welfare Centre will be situated
in the area of population served by it.
Its 5
fields units will be disbursed around in the area
of operation.
(2) The Mini Family Welfare Centre will be attached for
clinical and referral services
------ j •'to the nearest PHC
□ ftcommunity Health Centre of Urban Centre
city area or voluntary Organisation Hospital/
Clinic to be specifically earmarked in this
project.
(3) The Mini Family Walfare Centre will
serve as a
depot for sujpply of contracoptives like condoms
and oral pills.
(4) The Mini Family We Ifare Centre will serve as au
a™™ unity . uplif t by (i) Imparting Health
Education (li) training married young women in
e art of motherhood? (iii) Immunisation in
c ildren and mothers? (iv) motivating the community
specially the target couples to 'have small
family norm and (y) ensuring proper sanitation and
hygenic conditions.
(5) The staff should be employed from the community
to be served s Pecially the grass root level work
the Family Female Voluntary worker' ’ 5 a h e 1 i ’ 0
(6) The Basic principle involved in the
success of mother
is to create rapport with the newly wed bride and
f6llow the c ouple through their reproductive phase ‘
including first pregnancy, delivery, post natal caro
?
... sP^cing of pregnancy, second pregnancy and finally
sterilisation.
During the folic.w up she will be
educated and helped as the need arises in various phases
step by step, ensuring a healthy marital life, healthy
eC1 .
y pregnancy period, safe delivery, healthy and
trained
rained motherhood and Finally ensuring spaced small
. . .3
family.
This step by step approach will provide
complete MCH cover and Family Planning.
This
approach will produce well trained mother who can
help other newly weds in her family and neighbourhood.
(a)
Methodology
In average there ore three to four marriages
performed each
marriage session in a village/cover area of an
average 800 to 1 ,000
population*
(b)
First Step
To establish rapport with the Newly Wed
this is done by
’Saheli*
ing her presence in the
s and their family and
(Family Female Voluntary Worker) by ensur-
marriage and creating closeness to the fami-
ly by presenting a small gift to the newly wed.
This gift may be
small and consist of csome general items of brides use.
In this
gift pack there should be nothing
„uulli)ly rexaTeQ
amTly Plcnning>
related xo
to rFamily
Planning, so that
no sensitivity is created in the
the family
family or with the bride. This
primary rapport with family of newly wed and the bride herself will
open the path for consequent visits.
(c)-
Second Step
The worker pays a casual visit to know the Wslfare Qf
wed and creating personal friendship with her.
newly
This may be done at
a convenient and congenial time.
(d) Third Step
During the casual visits
’Saheli’
(Family Welfare Female Vpluntary worker) may come to know about the
conception occuring in the
newly wed«
From this , the visits of the worker is goal oriented
and purposeful.
The worker should start educating the mothers
regarding the conception, pregnancy, nutrition, for mother and child
and few does
and doesnot in sanitation.
During this visit the
worker should congratulate and encourage the would be mother and
take her into confidence.
This is the best period when the young
mother is most receptive and inquisitive to learn about motherhood
in confidence through a friend.
(e )
Fourth Step
The would-be mother is gradually prepared to come to the Primary Health Centre/Hospital with the help of elder family .members
specially the mother-in-law.
Thus the routine ante-natal' help is
provided and would-be mother is told about healthy motherhood, pro
tection of self from tetanus, nutriative value of specific foods to
be taken and role of sanitation in pregnancy and delivery,
She is
educated for preparing clothe.se for delivery and the child to
come.
Complete checking is .done at the nearest csntre and if she
is a risk
case , she should be referred to Community Health Centre.
Thus at
. . .4
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(J-)
Jaqq.o
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auo
Unit coordinator will be a full time employee and primarily
Extension Educators and will be required to develop rapport with the
Primary Health Centres, Sub-Divisional Hospitals, Family Welfare
Centres and voluntaryorganisations, Hospitals/Clinics where he wil
be required to send the motivated persons.
In case of male unit
Coordinator he will also try to motivate the men in his areas for
adopting a small family norm and terminal and spacing methocs of
family planning.
Unit Coordinator will have a degree in Science or Social.
Science and Biology from the recognised University.
Preference will
be given to persons having two years experience in health care/
family planning activities.
(b)
Group Leader
Group leader will primarily be} a Saheli but she would also
responsibility to assist the Sahelies and act
be given an additional
<---as_ qroup leader of the unit.
She wilx establish rappott with the
Primary Health Centre, Sub—Divisional Hospital and other Hospitals/
main basic records to be passed over to the unit CoordiClinics and
c.-- ---She will help to develop a programme for motivation of
nator.
She will
• •
)' for
?_ a small family norm,
women in reproductive age group
support
to
Sahelies
by
visiting
family
etc.
extend
(c)
Saheli
There will be one> saheli for a population of urban area anc 6D0
The saheli will from the Anganworii worker/Balwadi
in rural area.
T..
workers or instructors or otherChild survival scheme from the units
‘ , The lady workers
located in the area of. operation of the project,
saheli
from community can also be appointed as j------ (i) if ebove narmer
workers are not willing.
(ii) due to special required• men , if the
Besides
the honorarium of Rs. 100/segment of population to be served.
j-e
.
»
■ i
i
ibenefits
. ...
_c* — Jl —.
X*
4- »—»
•! 1 "i r*> ■4*’ n n H
and
that
for
sterilisation
and IUD cases
p.m. motivational l— -----i
addition
in
accordance
with the
will be possible to the Saheli in
prescribed by the resjpective State Government.
Monitoring and Evaluation
This
This will
will be
be done
done each
each month at the level of PHC in rural set-up
and at district level in city set-up^by M. D. , . PHC/CMO
Project
Manager will present the report
in their regular meetings.
f_ J
unc'.er
various h ads likes —
regarding the work of the centre
(1 I )
1.
2.
3.
4.
5.
6.
7.
12.
Referral Cases.
MCH vJork
Motivation.
House Visits.
Educational programme
Training programme
Area profile.
Release of funds
Release of funds will be under the Central Sector scheme for
grant-in-aid to Voluntary .organisations. The amount of hs.66,7U9/
for moetinq the cost of implementation of the scheme during “n®
year period will be paid into two instalments.
The first instalment
for the six months will consist of full non-recurring exponuiture
and 50% of recurring expenditure. The second instalment will be
tiivsn when the project starts operating after completion of three
months of the project life on receipt of the progress report an
expenditure statement for the first quarter.
I
Co^ H cb'S
y
■ >
“Glon’hc^
~
-1
I II
SI V2
^SIS—3CK3>a;.
P . B.- N o -. 1• 1•
Co on o or - f"J
_---------
_,,--_.w>~rri
O t C Lys /18 /80.
5"th December,
1980
To
BER d - U P.«. SI.
Dear Sir(.)2
iNffaai-uTioN.
**
t rx e
Herewith 1
” TO 0 Chr on
1 c -le «’ on am enclosing' an extracts froa
--------
(a)
Pontajning- the rising cost
o£ELedical
care,
""
(o)
H o a 1 th care means
ni o r o t n an. doctor
The two topics
value to
extracted would be Of
groat
manag-ors and medical of'i'icers alike.
Yours faithfully,
t J I
i'
.. • ' G.
'
-Dr. (hrs. ) V. y -
^ahamathullah9
En c 12 * *■
C op y t o s
Medical Adviser.
The President & Members
9
Executive Committe e •
The Convener & Members
9
Ri i r al D <>■ v a 1 <
11
tqnj.
r<,^Fnm L G i, o
CONTAINING Th2 RISING COST_OF
MEDICAL CAR3.
(Extract from WHO Chronicle 9
3U 408-412(1977)
This is based on a paper prepared oy Dr.B.i'.
KIe c zk owski? DroJS.P. Mach, and Dr.R.G. Thomas, for a
meeting of experts on raising medical care costs held
in Geneva, in May 1977 under the International Labour
Organisation.
To help contain costs, administrators are asked
in this article to consider (i) revised structures of
benefits that would accord at least equal treatment to
outpatient and home care, prepaid group practice, and
other less costly types of care;
(ii) better cost
accounting to permit more accurate measurement of the
relative costs of different kinds of care’
(iii)
measures to increase the cost-consciousness of physic!axis and the public^
(iv) various ways to contain the
costs of drugs 5 and (v) how to promote self-care.
For
the longer run the article examines the role of preven
tive medicine in cost containment.
1.
By making care ever more widely available at
1 i t tie or no direct cost to the consumer,
consumer9
it increases
demand for services more rapidly than supply.
2.
By being too often considered as simply another
way of paying for existing kinds
of medical care without
providing incentives for changing to
more rational methods,
less expensive,
it helps perpetuate the existing
bias towards the more costly kinds of
treatment and does
o
not strike at the root of increasing costs.
For the relatively wealthy industrialized
countries with schemes already in force, the costs are
verging on the intolerable.
For developing countries
2
2
looking* to social security as a means of expanding
medical care but from a much smaller resource base,
tj ese distortions can nullify the potential of social
security to provide improved care for wage earners an,d
can broaden the already wide gap between health
cars
for the urban v/orker and that for his
rur a 1 c oun t orp sj? t.
These are the reasons why cost containment , or at least
a process of rationalization, is being- subjected to
increasingly close study.
hospitalizations
Too often, plans provide maximum benefits only
for treatment in hospital, tThereby inclining* patients
to opt for (and, equally, physicians to prescribe) this
most expensive of all forms of treatment 5 even when outpatient or home care would be as good or better and less
expensive in many cases.
This bias is reinforced by the
widely held public impression tthat
ha t only the latest tech
nology and newest medicines administered by the m o s t
highly skilled specialists
of the sort available only
in hospital - can provide effective treatment.
What is
overlooked is that, once in hospital, the patient is
often caugx^^ up in a medical care chain without real
incentives for reducing costs.
typically, toe patient himself does not care about
the cost of treatment because "someone else” is paying
for it.
Tile phy s i ci an who prescribed the treatment has
neiti-j er th e in c e nt ive nor often even an awareness of
.. 3
3
the need to bej cost-conscious because he bears no part
of the cost.
The hospital, as provider of the pres
cribed services, is riot likely to inquire too closely
as to the usefulness of the treatment or its cost, so
3
long as it is assured of receiving- paymant.
tne tnird party,
Finally,
Finally
once he receives the bill that includes
all the costs passed along through the chain, is poorly
positioned to question charges after the fact.
Witt hospital costs as the largest and most
rapidly growing component of the total cost of medical
care, they become an important target for efforts to
contain costs.
However, because medical care, especially
in hospital, is so labpur-intensi vg , staff salaries alone
amount to -as much as 7o/a of the oporating costs, which
cannot be reduced significantly without affecting servic os
advorsoly- much the same is true of the other major
hospital operating costs.
it is thus necessary to look
for greater operating efficiencies and, more
more particularly,
for better use of the available supply of beds as the
primary means of containing costs.
.advanced technologys_
Ariot 1. or important contributor to the explosion
in the cost of medical
Caro has been the uncritical
acceptance of new technology and the
very expensive
devices necessary to put this technology
into practice.
idiether prompted by high public expectations of yet
an other m i r a c 1 o 11' ® a tin on t, ci propensity to equate the
latest with the best
or a competitive desire for
.. 4
z
4
prestige in a medical version of "keeping up*with the
J onesosn9
teis attitude loads to investment in costLy
■j
techniquos and facilities9 which are nOodod by only the
9
most seriously ill, who constitute
of those- needing health c aj? e .
only a small fr .ction
'/hat
t 1.5 means in economic terms is that, while
health has
the base of the mediccl care cost
ar a much more widely available,
pyramid by making ccare
advanced technology contributes to raisin.; the height of
Taken together, these two factors result in
its peak.
much higher tot'1 cost rather than more equitable distri
ct! t 1 o n of sorvicos according to needs.
i t me ans
in oxtreme c as e s ?
ti at tho technology itself determines who will
be treated rather than social need,
other jioro traditional
factorso
Medleal mano ower costs
This bias
a v i c i oU s
c 1 r c 1 e;
towzards hospital treatmoat and advanced
technology boars both directly and inciroctly on the cost
of me^dical manpower.
By requiring a
staff of
specialists to take full advaatn - of the hospital’s
facilities 2
tnis type of medic;.! care draws upon the most
highly tmineds and thorufore most expensive3 members of
the medical profession. Also it usually involves more
different kinds of care than simple regime?&
•adding to costs,
thereby
y.e t pro du c in g f o w ru e as u r a b lo he a 1th
advantages in terms of either mortality o r . : o r .) i di ty ,
5
5
3
How to contain medical care costs:a” R*dmr.
1 o
ibi— ■wc'—imi—w«r—m—tw iwmw-um —mtib iri . w— tiw ta—r- —rx
Rgvised benefit structuro;
By changing the
structure ox health benefits so as to accord more equal
treatment to health services ot her t han ho spi t a1 care,
Cog. y xxvfuiAu;
home V-/X
or outv Cl
ationt
u X^ix V u-ctx
c ar t;
e ? administrators could
provide a financial incentive for both patient and pres
cribing physician to consider the full gamut of possibi-
lities for treating a. p?ar ti c u 1 ar a i Im e nt 9 perhaps arriving
at a less expensive 9 but equally effective9
inpatient careo
alternative to
In facts recent studios have increasingly
emphasized tnat the organization of medical services may
be second only to morbidity in determining hospital utili
zation.
In one example of prepaid group practice in the
USA9 emphasis on outpatient and preventive care reduced
hospital use by about 50% within five years» the latest
report indicates that the rate of hospital utilization
by this group practice oven after a number of years was
about half that of a similar group in the same city
participating in an open fee-for-sorvice plan.
Similar
experiences in socialist countries
u±
o 9 where fully Integrated
services give equal emphasis to curing 2 prevention,
rohabili t at i on ? and social services ?
su.grjoct, tho.t this-
approach provides a useful basis for selecting the care
actually required by individuals and most convenient for.
them.
hospital car© thus be comes but one a11ernat ive
among a number of options.
2
Bet ter co st accounting;
Arriving at an accurate
estimate of the overall savings that result from this
substitution of one kind of health service for another
..
s
6
has proved to be difficulte
2
Most current accounting
systems divide costs along administrative lines, i.e.,
staff, equipment, drugs,
etc., or lump them together
into simpler units such as cost per inpatient day or per
hospital bed.
They also tend to ignore such essential
as the degree of health risk or the gravity of
variables as
the problem being dealt with.
Thus, they cb not lend
themselves to making meaningful comparisons of the costs
and benefits of dealing with a given health problem in
different ways.
Recently, however, there has been progress towards
developing systems of standardized cost accounting for
each medical care programme that pinpoint the relative
cost of each and make it possible to evaluate the most
costly kinds of treatment against the benefits resulting
from them.
To know that the same benefit can be obtained
at lower cost is clearly to the advantage.
3o
Piousness ;
Since the physician
in most cases decides how much and what kind of medical
c ar o -is patients ’•demand” and such demand more or less
automatically follows supply, he has a potentially vital
role to play in cost containment.
Yet most physicians
are poorly equipped by both training and personal incli
nation to perform effectively in this role.
Few medical
schools devote any attention at all to the basic economics
of me-dical care§ instead, the atmosphere of a lavishly
e qu ip ped h o sp i t a 1 j whether deliberately or not, tends to
create a predisposition towards the latest, and often
the most expensive , in diagnostic and therapeutic equipment
7
i
7
and techniques«
The sense of professional pride
inculcated into
lae-dical students while in training
inhibits many practising physicians from considering
from
community nurses, family heaith vorkerSj and
workers
Physician extenders” as qualified
to perform a
qualified to
significant portion of
of their
their routine
routine medical duties,
While
none of these attitudes
s and viewpoints is likely
to be
^•u^ceptible to rapid change, least of all, there are
signs of growing cost-consciousness on the part of
Physicians? these must be encouraged by every available
means.
4.
Cos t of drugs ;
Another important factor in the
upward pressure on the cost
of medical care is the large
and increasing c onsumption of drugs,
both by prescription
and for self-medication,
In France during a recent year 9
for example? over 18% of all health
insurance expenditure;
went to pay for drugs used by outpatients,
For all of
Europe
it is estimated that the total bill
for drugs
amounts to more than 10% of the funds
spent on health
sorvicos.
Unlike other components
oi medical
care costs,
of medical
the pattern of
increasing drug consumption appears to be
relatively independent of how health services
are organized,
The USA with its liberal system
the United Kingdom wi th
its National Health Service
, and Poland with its centrally
planned and run system all have
similar patterns of
increasing drug US Q 9
In fact
the rate of increase of drug use and the
types of drug us ed
appear to depend primarily on the
number of preparations available
in the market for either
. . 8
I
8
self-medication or prescription use and on prevailing
prescription practices.
For example, the volume of .
drugs attributed to 3eIf-medication amounts to 35% of
tota.1 drug consumption in the USA, 22% in Switzerland,
and 18% in France.
Consumption of acetylsalicylic acid
(aspirin), the drug most
commonly self-administered,
averages pver 60 tablets per person annually in Europe
and as high as 225 tablets in the USA.
Adding to the volume of self-medication is the
market tendency towards iiiappropriate
of
inappropriate prescription
prescript!
drugs.
Perhaps prompted by the patient's belief that all
medical consultations,9 to
to be
satisfactory, must result
be satisfactory
m a prescription o;r
or for other reasons,
physicians seem
reasons
all too willing to prescribe
whether or not they
prescribe drugs,
drugs
are needed.
In the US
a, it is estimated that the great
USA,
majority of all physicians engage in tjiis practice;
there, 60% of all drugs prescribed against the common cold
*ere antioiotics and sulfonamides,2 which are both expensive
c.nct ineffective in such cases.
l/i bn this combination of excessive public reliance
on drugs and the tendency of physicians to overprescribe,
governments have tried a number oi regulatory measures.
To help physicians sort out the conflicting advertised
claims made for the increasing numbers of‘drugs being
marketed by the pharmaceutical industry, some governments
have set up neutral advisers on
orug information
on drug
information at
at the
state level and have limited
limited the
the promotion
promotion of new drugs t o
factual statements only.
;to
at is needed
needed, in addition, is
itfliat
broader public awareness and understanding of the proper
role oi drugs in treating disease.
.. 9
’
2
9
$
They can promote the concept of "essential drugs n
whereby drug purchases are concentrated on those drugs
that are of proven efficacy against defined health problems
and are available at a reasonable cost.
-5 •
SeIf-carej
The often overlooked fact that aS
much as 75^ or more of all health care is undertaken with
out professional help provides another focus for efforts
at cost containment*
Despite some opposition from the
more conservative elements of the health professions,
it
is estimated that about
of all illness episodes seen
in general pra.ctice could be treated entirely through
self-care and another 15$> or so would have a better out
come if supplemented by self care, particularly "guided
self—care” by which the patient would learn to understand
his ailment and what he can do about ite
For example, in a controlled experiment that taught
a
group of haemophiliacs and their families how to manage
their bleeding problems, the rate of hospital usage was
reduced by 9O70 over one year, with equivalent savings in
hospital costs,
Moreover, absenteeism from work or school
was cut by
outpatient visits by 76%, and the total
cost of healthecare by 45%
In another example of guided
self-care, a telephone "hot line" installed in a clinic
treating diabetics resulted in a two-thirds reduction in
the incidence of diabetic coma and a nne-half reduction in
tne number of emergency admissions over a two-year period^
this occurred despite an increase in the clinic population
from 1000 to 6000.
10
s
10
Guidod self-care does not always
provide such
immediate benefits because of the
time and money spent
oh providing training, but once the
training' is completed
it can provide a low-cost substitute
for professional care
that is immediately available
and can be adopted, to the
needs of the patient,
Self-care by patient can also have
an important bearing
on reducing costs by making doctors
prescribe treatment more responsibly.
I
J.
The five contalnoont laessures Just
he curative component of health
care within bounds since
this is where the bulk of
medical care funds are spent,
even though such expenditure
xiave been shown to have
little effoct on the
general health status of the
p op u 1 at i on.
One final .
Reasursaprevention is likely to
command a greater
share of future funds as
accumulating scientific knowledge
but tresses existing evidence
hat genetic and environmental
factors 9 plus human behaviour
and life style , rather than
disease are the
major determinants of health0
Schemes
should thus be propaired to provide
support and encouragement
to cost effective progr a nme s
of preventive medicine«
These programmes include
early identificat ion of
those at high risk of chronic
di s e as e an d giving individuals every opportunity
and incentive to ichange their
life style.
Another approach to
prevention is the early
detection of disease.
ihe cost of systematic medical
screening of
every effectively treated case
case is often
substantial, P cxx t i c u 1 ar 1 y wh en applied. On
a mas s scale.
11
<
i
11
i
None the less,
there is sufficient epidemiological
evidence to indicate that tho incidence of many chronic
conditions can be significantly reduced through prevent.: .
c ar q by putting into effect what is already known about
them 9
thus reducing the burden of chronic care which
h o s p i t ■ .1 s are so often called upon to finance.
^hat is
missing are the- economic incentives,
necessary motivation
of healthccare providers and consuinars, and the kind of
organizational structure that will make such achievements
although countries have come well past the old
and outdated notion of limiting health
coverage to confirmed
cases of disease, they genera11y have
some way to go in
bringing about the conditions that will permit
preventive
c ar o t o m ake a maximum contribution both to
containment of
medical c ar o costs and to the improvement
of heal th status o
This is the challenge of the future.
possible.
sspd.
5.12.1980.
<!
•<
V
E3ALTH CaRS MEANS M0R3 Ti^I{_QOCTpRS o
(WHO Chronicle - Vol.31,
***
1977)
Health problems cannot be solved by the health
This was learnt after much money and
sector alone.
energy went towards increasing the number of doctors and
hospital beds.
The idea was to model health services
after the examples of the wealthy developed nations.
Health is influenced by poor living condition, unsafe
water, malnutrition and wrong dietetic and some harmful
cultural practices.
Hence, today, extension of services
to where people live and delivery of health by people in
the community have shown much more promise of fulfilling
the desire of the century ’’health for all by 20C0
Communi ty he alth worker s 9 health auxiliaries and
para-medicals are able to improve the health of the
community at a. fraction of a cost of highly trained pro
fessionals.
They are able to pinpoint the underlying
causes of disease in the community and they are instrument al
in organising their fellow citizen to take action for health
Today■9 health care systems are changing their
perspect ive 9 away from big hospitals to the needs of the*
community.
'The emphasis is to link communities to the
health centres.
It must be emphasized that prevention and promotion
are the most important aspects of health care and needs
support from all levels.
The problem must be attacked
at its origin - the community,
)
s spd.
5.12.1980.
/
Com h c].|^
Vc> I iAr)
c<e^’
social work based, on the spirit of Sympathy,
Spiritual urge to help one’s fellow beings in distress visited
in different societies from the time inuaemorlal.
Ehagwat gita says "darity is valid if it takes into accourat
DSSE, Kai, and Patra. (Place, time andrecipient)
Kgulalaya hes mentioned in his Arthasastra the responsibility
for the care of the poor sged, distribite etc.
In king ‘‘shoka1 s foimi Gopas were like Social workers.
social work through religion
British '> erior and social reforms
Gan di lan Social work
post independence.
Public coporation
Voluntary
V oluntary
V oluntary
4 crores in 1^5 yr.
Govt. Public V oln.
1.1
11_’, bulk of the Scoial welfare Services in our country
T raditionally,
organised by voluntary agencies who with their long
have been playing on importent role in providing services for the
underprivileged.
Now there are thousands of voluntary agencies with lakhs of
workers in it about Gone of them are an grant in aid rolls in
cnetral Social welfare bound and /or with stats Govt, assistence.
' voluntary organisation properly speaking in an organisation which
whentlier its workers are paid or not is initiated and
governed by its own. members without external control Voluntary action is by its very nature local.
v'Non official agercies:-
Voluntary organisations are Sponthneous in their origin.
Won office! agencies may be sponussed by got;t.
G’naTWKT.jj 0? VJbUIJI
j pa
CASH
KIWD
VOIWISIS SERVICES
jh HOUGH
IMiliXtUaL
VOLUNTARY /.GlUbJIES
SUMI GOVT. AGEMGlEi
1. Voluntary through
agency
v oluntary Workers
1. i.dho Commirtes
2 paif- Workers
2. Forraanent
committes.
2. Personel Service
at individual
GROWTH 0FVaT.U1CTA!« AGEWCIES
1901 - I960
MO. OF AGENC11SS
pehod
Before 190r
107
1.7R
1901-10
71
1.13
11-70
138
7.30
21-30
303
5.05
31-4C
52?
8.70
41-50
1350
22.50
51-60
3763
54.39
246
4.10
6noo
loo.oo
No. inforasatlon
TOTAL
waM8RR OF INSTITUTION ACCORDING TO TKs SFONCOING AGaMGlES—
S a States,
R ■ Religion organisations
0 -s Otters
T 3 total
-r-
S
0
7
3
R
0
I .
A.P.
15
290
305
My.
77
381
408
ASS.
7
337
344
Or.
11
232
'43
Bi.
15
213
■r^A
Pun.
8
142
150
Gu.
19
539
558
BaJ.
11
268
279
J .X.
2
19
21
U .P.
13
312
325
K«r.
73
520
593
W.B
77
869
946
M .F .
9
241
250
Del.
7
87
94
Wi.
52
359
411
Otters
9
65
74
MH .
61
710
771
416
5584
6000
6.9<
93.14
Total
100*
INSTITUTIONS WOFNING FOB IH. WBLFAH
______ HANDICr.blr.:,D k,i-S0NS____________
0?
X
Total
Run by Govt.
Run by
Gate.,ray
V oluntary
of Beneticial9R.es._____ ____ a££Sw;l&£
NO.
NO.
%
NO.
%
bLINI)
115
55.1
16
55.?
in
55.1 \
DEAF 3t
DUMB
6n
7R.7
11
37.9
71
?9.8
CRIppltD
n<->
10.5
6.0
”4
10.1
MWx.LL'f
12
5.7
1?
5.0
■’OO
37.8
?38
too
TOTAL
79
17. ?
OF Gh.Ni,-;
.UB.t2-ia.6g.
NO. 0? AQt.N,
cies
*
Amount
in croies
Child Welfare
7337
39/&
0.63
43.i
Womens Welfare
7920
49%
2.06
37^
Welfare of the
handicapped
743
4%
0.62
10%
general welfare
468
8%
0.65
10%
TOTAL
5960
6.16
6.16
1O0
mo
-■
DIST BI EUT ION 3? TH AMOUNT SAKgflQNED
ACOaRDlKO, TO FIKT.B OF 3K29T0F.
TQT AL 6-16
740 T ;Xi!3 S^WlONhiD.
3T:;T-^
S tate
Child
welfare
Women
welfare
Welfare
1G eneral
of the
welfare
handioapped
A.F.
^.10
15.51
3.76
7.75
41.62
uu.
19.18
20.98
4.03
3.84
42.03
Mad.
79.49
17.38
,ff.93
3.65
58.45
Maba.
33.63
28.43
13.31
6.74
86. S3
Mys.
21.88
15.85
2.69
4.55
44.97
U.P.
13.33
14.61
4.82
11.41
44.17
W. B.
79.91
37.21
4.34
8.76
80.27
TOTAL
063.59
275.66
62.06
64.78
616.09
40 i
354
nJ
134
100/4
Total
ACTIVITIes OF w .H.0 ,
1.
Strengthening of the health 3 ervices.
Family Health.
3.
health Manpower development
4.
Communicable disease control.
5.
Won.
6.
Immunol ogy.
7.
t-
Tl
Fl
8.
I rophyl actio, diagmovtic and Therapntic Substance.
Environmental Health.
9.
HEalth statistics.
10.
Eiomedlcal research.
11.
health literature-in formation.
12.
Cooperation with other organisations.
F araily H c al th.
M.a.H.
HUTRIT ION
HEALTH EDUCATION
HUMAN HEFhOEUCTION.
Improved manegewm of preg,
rlxMbltjr pegBlatlon
Promotion of growth of young children.
Prevention of diseases during pregnancy and childhood.
F romotion of the health of the family.
F.P.
MQH centres in 70 projects in 6b countries.
In lndi5 community Tinted teaching in Frediatrlcs
Special fading & r diildren.
(with UMCEF and other organisations)
At the 36th Session of the regional Committee forS.E.A.
the folio-wing 4 areas were re commended as diserving hij^i
regional priority.
1.
Com-municable disease control
oe
Family health
3.
Nutrition
4.
Frevision and maniterance of water suply and drainage.
Higi birth and death rates (metemal and infant mortabily)
emphasige the importance ofxness-cx necessity of according high
proiority to family health in S.E.A. region.
1976to 1977
- MCH and y.P. will be included into
general health sercices.
special health measures againest malnutrition.
Which is the other agencies
Development of Community health Nursing Services
(1.
6)
Strengthening of the depts, of Pac, Obs. and PdS.M.
( 1958- 77')
Applied Nutration programme
(1964)
Nutrition traning
Health education in Sidioois, including family life edu.
Central education
Blindness prevention.
OFr.ICUl.,
Or’ WhQ. 1*0.
Proposed programme Ludject for the financial yr.
1976, 1977.
No.
Regular
1974
739745
106637?
130 5517
7.1
71469109
1975
770850
1654514
1875364
8.1
701647?
1976
77173A
14467177
1668467
9.1
17417157
1977
725370
1734-380
959750
7.5
1390:3241
Other
Total
7 otal
For r* eironal and Child health.
rr
:
•’ A
J. i,
Ked Jrpss
Meternity and child welfare as ar integral part since 1931
to ass it in MCI!.
gives
‘TedinicaZI and i'irancial assistance
Health education
Kits to mid-wife
Special welfare programme in U.P.
family welfare planning.
ford Foundation
Manity rural health services and F.P.
W
1.
Orientation and training centres.
2.
Research cum action projects
3.
rHot project in rural health services (gandtigra)
4.
LstablishEiert of FIHhL.
5.
Oaleutta water suply and drainage scheme.
6.
F.p. pxogramaes (follower lips)
Ko c'-r ef el 'I erf ound ,?t ipn
To promote U t well’ being of mankind.
Begirir g
Full ic health ar.'’ Medical education.
India
IST.
,<orm control - Madras.
A.l.I. Mygine 4 pub. He.
Now
Culbutt a.
for
Improvement of agriculture.
Hural training centres.
Medical education.
F.F.
CJ.EB (cooperative for American Belief Every whei-e) 1946.
1961 tn India.
Mid day meal programme.
USaID
( Unlisted
USA1D ( United _»ates agency 'or international development)
Control of Coramunicable diseases.
Water suply and Sanitation.
Medical, Nursnig and Health education
Nutritions
?.P.
Col omboplar
HUMS
UNICEF-
(Newgul and)
Education
rtskfcx K eal th
Nutrition
Applied Nutrintion programme.
Water suply
986 Blocks.
Social Welfare
147 I rain it g Institutions.
Industry
n€? Production centres
UKfr
Edu cation
H et.lth and S oci al W elf &re
1.
!*
Voluntary Social Welfare in India
By D.Faul Chowdhary.
Official I.ecords o: W JI
1971.
.
3.
Official records of W.k.O.
The work of WHO
4.
Henry Dunant and Bed Gross.
By H .N. Fardit 1966.
5.
51st Annual Report, Indian Fes cross xeoi Society
1971.
6.
The future of Fhilafflthaophic foundations
197.5,
foundations ^yaposiurn.
7.
Text book of preventive and Social Midloina
by J .E park and K.Bark, 1976
8.
W.^.O. Chr.
9.
World health
No.
1975
799.
24. 489. 197T!
April 1963. The bed cross
GOVERNMENT CF KARWAKA
DIRECTORATE OF HEALTH AND FAMILY WELFARE SERVICESt BaNG/WORE
jgAWHjh-ip ,FAMILY WELFARE COMPCHECTS AVAILABLE FREE FOR HEALTH C7RE DELIVERY THROUGH VOW CT ARY OBAPTSAT IONS
SI.
No •
Programes
Beneficiaries
Methodology
1
2
3
4
Objective
5
Role of the voluntary;
organisations
Romrks
6
7
NUTKl TTCH HlpPHmXIS BOGPAMMBS
1.
2.
Iron and Folic acid
tablets for mothers
(lron-60mg; Folic
acid 0.5 mg.)
Expectant and Nursing
nothers, wonen Family
Welfare acceptors•
1 tabldt to each of
Prophylaxis against
these wonen daily for Nutritional Anaeni;
100 days.
Iron and Folic acid
tablets for children
(iron-20 ng Folic
acid 0 .1 ng)
Children below 12
years of age School
going and pe-school.
1 tablet daily for
100 days
do
do
do
Once in 6 nonths
in the form of
capsule or liquid.
For preventions of
night blindness^
Keratomalacia and
other complications
due to Vitamin ’A’
deficiency.
cb
1 • This programme is
taken up in the
rural area at pre
sent •
2. To be 'obtained
fron PJI.C. or
sub-centre•
Volun tary organis a tions
can distribute these
drugs to the beneficia
ries •
1. Monthly quota
to be distri
buted cnee in
a month. List
of beneficiaries
to be maintained
in prescribed,
form:
2. To bo obtained
from D.H. & F.W.O./
P .H .0 ./Sub-centre.
5
23 I
g
on
O o
.H
- S’ O
o
Vitamin ’A’ concentr AU children fron
ated Sol.2 lakhs units 1 to 4 years.
strenght•
n
o
cz?
Contd/2-
: 2 :
1
2
3
7
6
5
4
TMMJ1HSATI0N FROGrniLjS
1.
D .P .T.
A11 children fron 3 months
to 3 years.
Start at 3rd month
and 3 doses at an
interval of 4 to 8
weeks with a booster
dose 18 to 24 months
later•
Prevention of
Diphtheria,
Tetanus, per
tussis (whoo
ping cough)
x
Completion of 3 doses. 1. Vaccine to be
stored in re
Voluntary organisations
frigerator at tc
can organise immunisa
of 4°° ‘to 10°c.
tion campaign in the
rural area and slums in 2. To bo obtained fj
D.H.& F.W.0./P.I
F.W.O./P.r
the urban areas and
D.H.&
carry out the immunisa
tions .
2.
3.
D & T
T.T.
4- B .0 »G. Vaccination
All children between 3-8
years•
Prevention of
Two doses at an in
terval of 4 'to 8 weeks Diphtheria and
Tetanus.
(Primary Vaccination
i.e. no DPT previously
given) Booster dose in
case of previous DPT
after an interval of
one year.
/ditenatel cases
In case of antenatals
3 doses-starting 1st
dose at 16-20 weeks,
2nd dose at 20-24 ■
weeks & 3rd dose at
36-38 weeks•
Prevention of
Tetanus
3 nonths to 19 years
Earliest at the age
of 3 months
Prevention of
Tuberculosis
F- - ■
Completion of 2 doses
or one bocstcr dose
Voluntary Oranisations
.can organise immunisa
tion campaigns in the
rural areas and slums
in urban areas and
carry out the immuni
sations •
Voluntary organisations
can t ake up as a part of
M3H Service and immunise
anatenatals•
do
do
Voluntary organisations 1 . Vaccine to be sJ
can arrange mass immuni in rogrigerator
sation programmes with 2. Vaccine availal 1
Bist. T . Cent:
the assistance of Distw*
T.B. Contres.
..,Contd/3-
: 3 :
I
1
'
2
3
4
SnaXLpox Vaccino
Trinary only
At the age of 3,-9 nonths
Polio Oral Vaccine
All children 3 to
9 months
Start at 3rd month and
3 doses at an interval
of 4 to 8 weeks with
a booster dose at 1g to
2Z months•
5
» Loop
• Mrodh
7
To prevent smallpox Voluntary oranisa- 1 • Vaccine to be
tions orn take up
stored in refri
as part of MCH
geration.
services and con 2. Vaccine available
duct Primary
at the PHO
Vaccinations•
To prevent Pol5 p
do
1 • Vaccine to be stored
myelitis
at - 20°c.
Likely to be available
during next financial
year.
. :HLY •^LF/-RE r-ROGPAMiES
Sterilisation
6
Couples v.ith two ■
children and above
Vasectomy, Tubectomy
Permanent method
for limiting the
family.
Couples with one or
two children.
Loop insertion
1. VoluntaryOrganisations can organise
sterilisation amps with the assistance
of local Primry Health Centrc/tJrban
Fanily Welfare Centre.
For spacing the
children T emporary
method of Family
Planning •
2. ifotivate eligible couples for undergoing
sterilisation, IUD insertion at the
nearest Prim-ry Health Centre or hospital.
They can act as depot holdems for distription of contraceptives. They can ensure
follow up services by the staff by closely
associating with Frina.ry Health Centre/
Urban Cont.ros and the Community.
3 • They can establish Urban Fann 1 y Wei faro
Centres in areas left uncovered by
Government institutions after approval
by Government. 100$ assistance will bo
provided by Govt.
Newly married couples, 6pioces or more at a time
and couples with one
depending on usage. Distri
child•
bution once a month.
For spacing the
children Temporary
method of Family
planning.
• • • .Contd/4-
: 4 :
2
. Oral Tills
Medical Terni*nation of Frognancy «
3
Couples with one or two
children•
Pregnant wocian upto 20
weeks where pregnancy
is unwanted.
4
5
6
7
4* Volutary organisations having their own
For spacing the
Oral pills-first 3 cycles to
hospital, approved by Government for
bo distributed directly under children-T enpoconducting tubectomy operation can main
the supervision of doctor and rary method of
tain sterilisation bods for which bed
Family ELanning*
when there is no untoward
maintaincnce charges will be paid by
effect, pills may be distriGovernment as per rules*
tod by non-medical per sonelie*
Beneficiaries to bo examined
5* Private Practitioners recommended by
by a doctor once in 6 months
Local Indian Medical Association and
or earlier whenever indicated.
approved by Government can take up
Medical institutions- (Private To safeguard the
vasectomy operations and IUD insertions
health of the
or Government) recognised
The beneficiaries eligible for ccmpensa
under M .T .P • Act can taken up beneficiaries aS
tion amount. The Private Practitioners
a welfare measure*
this programme*
are eligible for service charges at the
prescribed rate fixed by Government
provided the services are rendered free
to the community. They can also take r
distribution of contraceptives includin
oral pills.
6. Nursing homes run by private practitior<
and voluntary organisations, satisfying
all the conditions as per M.T .P. Act
and recognised by Government can take uM.T.P. Services.
ffE; (1) Iron Folic acid tablets, D.P.T. Vaccine, Diptheria and Tetanus, Vaccine, Tetanus-Toxoid, B.C.G. Vaccine, Small-pox Vaccine,
B.C.G. Vaccine Contraceptives are available Pree:
(i) depending on the availability of stock with Government.
(ii) depending on refrigerator facilities available with the organisation.
and (iii) provided the services are rendered free to community.
Contd/5-
Com h
INTERNATIONAL CLASSIFICATION OF DISEASE
Modified LIST *0*
to be used for monthly statistical report from
•C’
MALLUR HEALTH CO-OPERATIVE CENTRE.
!♦ Typhoid, Paratyphoid A Salmonellosis
2. Bacillary Dysentery & Amoebiasis
5a. Cholera
5b. Gastroenteritis and other diarrhoeal diseases
4« Tuberculosis (Respiratory)
5* Tuberculosis (All other)
6. Brucellosis
7. Diphtheria
8. Whooping cough
9. Sore throat and scarlet fever
10a. Small pox
COMMUNITY HEAtTH CEU.
47/1, (First floorlSt. Marks Roa«
3HN ; lG -i S50 001
10b. Chickenpox
Ila. Measles
lib. Mumps
11c. Poliomyelitis
12. Viral Encephalitis
15a. Infective hepatites
15b. Jaundice due to other causes
14• Typhus and other Rickettsioses
15. Malaria
16. Syphilis and sequelae
17a. Gonococcal infection
17b. Other veneisal diseases
18a. Ascariasis (Roundworm)
18b. Oxyuriasis (Threadworm, pinworm)
18c. Other Helminthiasis
19. All other infective and parasitic infections emcluding l-18c
20. Malignancies
21. Benign neoplasms
22. Thyroid diseases
25. Diabetes mellitus
24a. Malnutrition
24b. Vitamin defficiencies
....2
H '
r
2
25• Other endocrinal and metabolic disorders
26a. Hookworm Anaemia
26b. Anemia due to other causes
27. Mental diseases
28. Diseases of the eye
/
28a. Inflammatory
28b. Foreign body
28c. Other diseases of eye excluding 28a, b and cataract
29. Cataract
50. Diseases of the ear
a. Furunculosis
50b. Otitis media
50c. Mastoiditis
50d. Foreign body
50e. Any others
51. Diseases of the nervous system and sense organs excluding eye and ear
52. Active Rheumatic fever
55. Chronic Rheumatie heart disease
54. Hypertensive heart disease
55. Ischaemic heart disease
56. Cerebrovascular heart disease
57. Venous thrombosis and embolism
58. Other diseases of circulatory system
59. Acute resp infections
40. Influenza
41. Pneumonia
42.a. Bronchitis with or without emphysema
42b. Asthma
45. Diseases of Tonsils and Adenoids
44. Pnamoconiosis and related diseases
45. Other diseases of the respiratory system
a. Coryza, Rhinitis and sisusitis
b. Pharyngitis and Laryngitis
46. Diseases of teeth and supporting structures
a. Dental cares
• •..3
u' *
5
46b. Dental abcess
46c. Any other infection or ulcers
47. Peptic ulcer
48. Appendicitis
49. Intestinal obstruction and Hernia
50. Gall bladder disease
51.a. Other diseases of digestive system - indigestion
51b. Any other
52-55. Diseases of the kidney and genito-urinary systems
56. Abortion
57. Other complications of pregnancy, childbirth and puerperum
58. Delivery without mention of complication
59. Infection of skin and subcutaneous tissue
a. Scabies
59b. Ringworm
59c• Boils
59d. Paronychia
59c. Other infections
60. Other diseases of skin and subcutaneous tissues
61.
Arthritis and spondylitis
62. Other diseases of musculosteletal system and connective tissue
63. Congenital anomalies
64. Certain causes of perinatal mortality
65, Other specified and ill-defined diseases
66. Road transport accidents
67. All other accidents
68. Attempted suicide and self inflicted injury
69. Attempted homicide and injury purposely inflicted by other persons,
legal intervention.
50. All other external causes
66N Fractures
67N Intracronial and internal injuries
69N Adverse effect of chemical substances
70N
All other injuries.
Position: 769 (6 views)