RF_COM_H_11_SUDHA_PART 2 (1).pdf
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Health And. Development
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1.1 Health.: L holistic issue
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standing in various spheres it has now been universally acknowledged
that health has much wider ramifications and ought to be perceived i
holistic perspective. This concept is reflected in the definition given y
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WHO (World Health Organisation):
Health is a state of complete Physical,(Me ntal and Social
well being and not merely an absence of disease or infirmity.
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Physical component pertains to the body, mental to the mind and
social to the entire socio-cultural environment. Therefore, it is evident
that factors from all these spheres have a direct significant role in shaping
and defining the health of an individual.
If we move further from the individual to the family, to the village
and further down to the entire community the interplay of these factors
becomes even more evident. This becomes all the more important when
we are working for the community and we have to cater services keeping
in mind that greater number of people are benefited. Hence, our efforts
have to be direct in such a way that greatest good to greatest number
is achieved. As development workers, we have often pondered as to
how is it that one section of the community has access to larger num oer
of resources and enjoys better health status and a larger majority lives in
sub-human conditions struggling and striving for survival? The exp anation to this clearly lies in an understanding of the social, cultural, economic and political factors.
.
In this context, it is also relevant to understand that WHO acclaims
health as a fundamental human right and has set up a goal for all
countries to achieve health for all by 2000 A.D. and the chosen strategy
is one of Primary Health Care. Primary Health Caro has boon dofinecl as obsc-. tial health care made universally accessible to
individuals fchd ’xccptoble to them, through their full par
ticipation and at a cost the community and country can af
ford.
HmlIUx r^motion through Community Action
i
13
1
Primary Health Care has the following characteristics:
1.
2.
3.
4.
It,is essential health care which is based on practical, scientifically
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sound and socially acceptable methods and technology.
It should be rendered universally, acceptable to individuals and
the families in the community through their full participation.
Its availability should be at a cost which the community and
country can afford to maintain at every stage of their developmen;
in a spirit of self-reliance and self-development.
It requires joint efforts of the health sector and other health ’
related factors viz. education, food and agriculture, social wel
fare, animal husbandry, housing, rural reconstruction, etc.
For effecti’ i primary health care the following eight essential com
ponents have been identified by WHO to be implemented in an inte
grated manner:
Greatest good to the
greatest number must be
the main aim.
1.
2.
3.
4.
5.
6.
7.
8.
Education of the people about prevailing health problems and'
methods of preventing and controlling them.
Promotion of food supply and proper nutrition.
Adequate supply of safe water and basic sanitation.
Maternal nd child health care and family planning.
Immunization against major infectious diseases.
Prevention and control of locally endemic diseases.
Appropriate treatment of common diseases and injuries.
Provision of essential drugs.
It is important to reflect as to how far or near are we in terms o!
these. And how much we, as development workers, are actually in
volved in this process. It is also essential to realize that we are very mud
part of the system, and health is “not merely” an issue in isolation, bu*1
very much a part of the development process.
1.2 Inter-linJ.a.ges between health and. development
Let us begin by refreshing our understanding of development. We all tall,
about development, we ail work towards development and we all wan:
our country to be developed. But what is development?
Let us reflect on the description given by United Nations.
UN description of development
“Human beings have basic needs; food, clothing, health, education. An
process of growth that does not lead to their fulfilment or even wors
disrupts them is a travesty of the idea of development. We are still in.
stage where the most important concern of development is the level c
satisfaction of basip needs for poorest sections in each society which ca;
be as high as 40 percent of the population. The primary purposes c
economic growth Should be to ensure the improvement of conditions fc
these groups. A g wth process that benefits only the healthiest minorit
and maintains or even increases the disparities between and withij
14
Health Promotion through Community Action
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He<h Promotion through Community Action
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countries is not development. It is exploitation. And the time for starting
the type of true economic growth that leads to better distribution and kJ
the satisfaction of the basic needs for all is today. We believe- that rapid
economic growm benefiting the few will trickle down to the mass of th’
people has proved to be illusory. We, therefore, reject the idea of ‘growh
first, justice in the distribution of benefits later’.
Development should not be limited to the satisfaction of bask!
needs. There are other needs, other goals, and other values. Develop
ment includes fijj’fedom of expression and impression the right to giw
and to receive ideas and stimulus. There is a deep social need to partici
pate in shaping the basis of one’s own existence, and to make sonic
contribution to the fashioning of world’s future. Above all, development
includes the righ. to work by which we mean not simply having a job bu:
finding self-realization in work, the right not to be alienated through’
production processes that use human beings simply as tools”.
It is evident from this that development is a total process and mar
is the most crucial factor in development. Starting point for development
is, of course, fulfilment of basic needs but it goes much further than that,
Development is uoth at the individual level and at the community leve;|
and is a process whereby people become more self reliant and at th
same time interdependent on one another. By development peopkachieve greater control over their lives.
Health and development are closely linked to each other. Some
view health as a pre-requisite for development, others see it as a by
product of development. In 1979, the United Nations General Assembly’
adopted health as an integral part of development.
Another very significant linkage between health and developmem
lies in the fact that health problems require both medical and social
solutions. Medical solutions alone are not sufficient to cope with health
problems because of complex entanglement with social factors. Support
ing this argument is the case of several diseases which have declined in
the Western coum; es. For example, Tuberculosis (T.B) started showing
a downward decli in the early 19th century and definitive treatment for
this disease in the vm of anti-tubercular drugs was discovered only in
the 1950 s. The reason for this can only be attributed to improvement in
the living conditions and overall socio-economic development in these
countries.
Hence, we see that road to health and road to development are the
same. It calls for an integrated network and close cooperation and
coordination in all spheres of which health is an important component
to achieve overall development.
1.3 Political TT ill
If we closely look at the health of any community and try to search for
. answers tto the following questions:
Who are
.
the people who get sick more often — is it the rich or the
poor?
16
Health Promotion through Community Action
Who gets
With
Where?
When?
vrhy?
Who are the people who have greater access to medical facilities?
Who are the people who are subjected to greater sufferings?
«r Who are the people who die more in number?
Evidently, the answer will be the poor. Therefore, the fight against
ill health is in fact, in its broader perspective a fight against poverty. T ns
essentially is a political issue and requires radical structural changes
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m .be teld of
wbld, m formulated and
implemented are governed bv political leaders. If we want changes or
alternatives a crucial determinant is whether the political system gover
ing a society favours a rule by an oligarchy or whetner it actively pro
motes changes in the social system which will enable the masses p
ticulariy the age long oppressed, under privileged and un
actively participate and to have their say in the affairs of the country.
l/there is a will and commitment in the political system to a process
of democratization and there is an equal amount of enthusiasm, and
Xon from the people then only can
alternative s^temi be
accepted and contribute in the process of overall cnange for better health
of the community and broade. development. An understanding of th;ls
concept is helpful in putting pressure on the rulers to bring about
^^IXy^the Concept of prir^ry health care has been accepted all over
the world and this indeed is a welcome sign and a healthy trend towards
greater democratization. This concept essentially requires
This means involvement of individuals, families and communities in
promotion of their health and welfare. It also implies that
should participate in planning, implementation and maintenance of heahh
services.
Cii'i Eauitable Oistri'ou'don
It means health services should be accessible to all sections of the
community and requires getting the health services dl5Per^
farthest reaches of rural areas and the deepest urban slums. The basic aim
is to correct all imbalances and bring health services as near as possible
Haalth. Promotion throxi^h Community Action
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to peoples’ homes.
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to the
(ill) Multi-sectoral approach.
It requires joint efforts of health sector along with other related sectors
viz. education, lood and agriculture, social welfare, animal husbandly,
housing and public works, rural reconstruction, etc.
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(iv) Appropriate technology
This means use of scientifically sound materials and methods that are
socially acceptable and directed against relevant health problems.
These indeed are quiet encouraging commitments but they should
not merely remain on paper or be of mere academic interest but they
have to be in practice implemented and guided by a strong political will.
What is happening today is that there is a wide gap between what we are
saying and what we are doing. There is a marked difference in what
objectives our policy statements talk about and what they actually come
up with and finally what is in effect implemented.
We, in the development sector, have to seriously reflect on what
constructive efforts we can make in creating a favourable political will, in
fostering an environment which is pro-people, in generating an aware
ness amongst common man for his rights and duties and overall accom
plishing development in its real sense.
1.4 Sound Alternatives
Common man often questions which system of medicine is the best? To
him the word Best” means a system which is less expensive and gives
early relief. Some aware people often want to know what are the adverse
effects of drugs which they are taking? Another very important point
which some people want to explore is how disease is caused and how
it can be prevented.
Commonly, it is seen that practitioners of each system claim their
system of medicine to b 1 the best. All of them try their level best to prove
that their system of meaicine is without any flaw and all other systems
have a number of flaws. Different systems of medicine operate differently.
There is no link or communication in between two systems of medicine
and even if there is some connection it is only for the sake of formality.
Who will have so much time that he or she goes through all the systems
of medicine and takes a decision as to which system is the best? In the
genesis or development of each system of medicine there is involvement
of innumerable persons and circumstances which have contributed. There
is no society, in which, in order to cater to the growing demand of various
health problems, some system of medicine or the other has not devel
oped. As time has progressed and science and technology has advanced,
there has been an advent of newer systems of medicine.
In India, normally, people use “Ayurveda” to denote the ancient
systems of medicine prevailing in our country, but in actuality, it is not
so. Various tribes and sub-tribes have evolved their own system of
medicine of which we know very little. Likewise, various herbal plants
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and medicinal plants have also been used based on socio-cmtural beliefs
and practices. In this regard, we would also like to mention that there is
a whole world of occult sciences which in their own way are contributing
to the systems of medicine.
,
“Unani”, “Homeopathy”, “Allopathy”, systems of meaicine have
come into our country from outside and today many of them have spread
quite extensively. Besides these in the South, “Siddhn and in Tibet
“Tibetan medicine” have evolved. Also “Yoga” “Naturopathy ,
“Magnetotherapy”, “Solar Medicine”, etc. are also being-used and prac
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ticed in India.
Today, communication media has added a new perspective to the
various systems of medicine. Health had been made a “commercial
commodity” and is being used for economic prosperity. R- !;o, television,
newspapers, and magazines have been used as aids in the process 0i
misleading oeople on health, issues. In order to make more and more
money in the field of health various techniques are being employed. Today,
the political will aiding this process and for multi-nationals money
,...King being the main objective, health improvement becomes a mere
slogan.
. ,
. .
“The Traditional way is good and the New Way is baa
this
approach line has also created number of problems for us. If we believe
that there is advancement in our knowledge we will keep with us some
of the healthy and good traditional practices and leavall the wrong
things, it shall be very helpful. We should look at all traditional systems
of medicine in a very open fashion and should avoid blindly following
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any one system.
,
If between various systems of medicine an environment. Oi mutual
trust and respect is fostered, it shall prove to be very helpful in the long
run. It shall also help us to eradicate all doubts naturally and create and
strengthen mutual understanding.
One
thing
is very clear that between various systems Oi medicine i
...... .......
ois not possible to have commonl ideological and philosophical understanding'because of fundamental differences. The ideology of Homeopathy
is entirely different from the ideology of Allopathy. Likewise, in Ayurveda
i whole world has been created through five states of matter, while m
Unani only four particles of matter are essential. Naturopathy advocates
do not use any kind of medicine and only use diet and certain processes
to find cures for various diseases. Ever since Yoga has reached the Wes.
this system has progressed by leaps and bounds. Yoga is based on
introspection and physical exercise. Acupuncture and Acupressure make
use of various needles while Magnetotherapy makes use of magnets to
cure diseases. •
.
As a result of experiments by China and some other countries i nas
been proved beyond doubt that despite ideological differences, a mutual
relationship can be established on the practical platform. In India, on a
very extensive scale, efforts are being made in this regard. But today
indifference and lack of understanding in professionals . td policy mak-
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Allopathy
ers has created an environment of unclarity
Today, some of the Ayurvedic, Yoga, Homeopathy practitioners are
freely making use of Allopathic medicines. In their training also the
advances of Allopathic medicines are taught. Even Allopathic practitio
ners are using drugs derived from herbal plants - e.g. Reserpine (drug
used for hypertension) from Sarpagandha and Vincristine (drug used for
Cancer) from Sadabahar. Whatever be the system of the medicine it is
incomplete and each system is trying to reach the state of wholeness. It
is scientific and logical to explore the possibility of change. It will be
wrong to assume that whatever is valid today, shall continue to be so.
In the evolution of Allopathic system of medicine there ha's been a
time when people were making claims that man would be able to get
himself complete rid of all diseases and be able to procure health but
this claim was sc._; disproved. Various diseases like Cancer, AIDS, etc.
have come up for which cure is not possible. On the other side there
have been various diseases like Smallpox which have been eradicated.
The field of surgery has also progressed in a big way.
If in this way we look at all the systems of medicine with respect and
objectivity and try to adopt the good points of each system it shall prove
to be a very useful effort. In this regard, however, we. shall like to stress
that even before finding cure for diseases it is still more important to be
healthy. The systei is of medicine which only talk about curing disease,
which use more am. more medicine and fill their pockets with the money
derived from poor, helpless and sick, which place doctors in the category
of gods, which believe a common man to be a fool, which believe in only
telling about health in terms of drugs and hospitals and ignoring the
socio-cultural, political and spiritual perspectives can only claim to be
systems appropriate for machines.
It will be wrong to imagine development of any system to foster
positive health without going into the socio-political, cultural, spiritual
dimensions. Today, we need a system which will eradicate the disease
from its root and create an awareness in general public about the cause
of the disease and prepare common man to deal effectively with it. It has
also to respect the socio-cultural values of the society and be available
and accessible to ail.
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TTZZG. Do you.
Tzith this definition?
List th© elements of primary health care. Do
you thinh these are essential*?
Discui;. the influence of politics on health of
the community of your region.
u He alth and Development are trvo sides of th©
same coin”. Discuss.
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BACKGROUND PAPER ON HEALTH AND PSM’S
Presented at 2nd All India People’s Science Congress,
Caleutta.
BY DELHI SCIENCE FORUM.
India was s signatory to the ii"Alma Ata Declaration it a
adopted by the World Health Assembly in 1978, which gave the
call Health for all by 2000 AD”. Today, 10 years after the
Alma Ata declaration, the state of health in India makes the-
country one of the most backward in this respect. The facilities
in some of our hospitals may be among the best in the world and
the same can be said about our doctors.
^his, however, does
not determine the health ofnation. The only true index of a
nation’s health is the state of health of the vast majority
of people, andnot that of a privileged few. In this regard^the
Government's own "Statement on National Health Policy”
(1982)
states The hospital based disease, and cure—oriented approach
towards the establishment of medical services has prodived
benefits to the upper crusts of societ specially those residing
in the turban areas. The proliferation of this approach has been
at the cost of providing comprehensive primary health care
services to the entire population, whether residing in the urban
or the rural areas”.
POST-INDEPENDENCE EXPANSION IN HEALTH SERVICES
However this should not detract from the fact that since
independence there has been improvement in many areas, both in
terms of growth in in restructure andinterms of their actual
impact on the health status of our people.
people, The following table
gives an account of the progress made.
Table
1
IMPROVEMENT IN HEALTH FACT LITIES/CONDITIONS SINCE INDEPENDENCE
Year
Life expe
tancy at
1951
1961
32.1
1971
45.5
52.1
57.0
1981
1985
41.2
Infantmort
ality rate
137
No. of
Populat ion No. Doctors
hosptla Is per bed
of
per lakh
PHCs popln.
2694
3199
725
16.5
3094
1930
2800 17.6
3976
1673
5112 25.8
120
105
6805
7181
180
16 5
1405
1378
Source: Comp11ed from Govt. source
. .2. . .
5568
7210
38.2
N.A.
-s 2
It is however important to understand both the content
and the process involved into this progress made in the health
sector, There is a tendency to cite the above figures to make
out a case for positing that this progress has been adequate, and
hence no .major policy interventions arenecessary. The health
services at the time of Independence were a function of the socioeconomic and political interests ur
of une
the colonial
colonial rulers.
rulers, Consequently they were highly centralised, urban-oriented and catered
to a small fraction of
population. Public health services
of the
the population^
were provided only in times of outbreaks of epidemic diseases
like small pox, plague, cholera etc. The post-independence
era
witnessed a real effort at providing comprehensive health
care/
and in extending the infrastructure of health service.
*
Even the West wemt through this rapid phase of improvement
of health services, after a period of stagnation, at the turn
of the century. in the early days of the Industrial Revolution
the bulk of workers who came to work in factories from the
countryside suffered from malnutrition, communicalble diseases
and high rates of infant and maternal mortality. When it was
realised that the very suffering of the people was endangering
industrial production (and thereby profits), active steps were
taken to dramatically imrpve publicchealth services,
services. Economists
who had considered medical expenditure
as a mere consumption
item, realised that allocation on
on health
health care
care was actually an
investment on increasing productivity of labour,
Another
major thrust was provided in the aftermath of the SecOnd
World
War, when with the rise of organised workingclass
movements and
the consequent development of democratic
consciousness in many
European countries the concept of "Welfare States"
was mooted.
. For example the National Health Scheme in Britain, which is highly
regarded even today, took shape under the Labour Government just
. after World War II. A rough analogy can be drawn with this and
the Indian situation after Independence. Consequent to the
transfer of power in 1947 the character, and as a result the
long term interests, <of' the ruling sections changed and consequently their intereest
-- and motivations were qualitatively
different from that of the British. Their own interests required a major thrust towards building of an infrastructure to
provide some basic facilities to the people. This thrust
was
both an expression of f
'
the
need felt by the ruling sections to
rapidly increase the industrial
- base and agricultural
production,
and a consequence of the concessions
<—
they required to make towards the genuine aspirations
--- ; of the people. This basic difference
between colonial India and free India, albeit under an exploitative social system, should be understood.
i
-s 3
At the same time major scientific discoveries
revolutionised
the treatment and prevention of many diseases,
These have
contributed greatly to the increase in life
: expectancy and
in reduction of mortality. The antibiotic .
era has made it
possible to control a larger number of infectious
diseases.
for which no cure was earlier possible,
Rapid strides have
been made in the field of immunisation,
diagnostics, anaesthesia.
surgical techniques and pharmaceut icaIs.
This has had a
dramatic impact on mortality and morbidity rates all over the
world. There are pitfalls of
an absolute dependence on technological solutions to health problems, but it is definitely
true that in many instances
newtechnologies have had a major.
impact, However the imporvements in ourhealth delivery system
have not kept pace with the needs of a vast majority of our
vast majority of
people.
so much so that the Government's
: “Statement on
National Health Policy" (1982) is forced
to state '’Inspite of
such impressive progress, the demogfaphic and health
picture
of the country still constitutues
a cause for serious and
urgent concern".
BALANCE SHEET OF HEALTH
The following statistics give a picture of the^state
of
health of our people?
_ Only 20%.of our people have access to modern medicine.
— 84% of health care costs is paid for privately.
— 40% of our child suffer from malnutrition. Even when
the foodgrain oroduction in India increased from 82
million tonnes in 1961 to 124 million tonnes in 1983,
the per capita intake decreased from 400gms. of cereals
and 69 gms.
of pulses to 392gms. and 38 gms. respectively.
Due to inceeasing economic burden on a majority of the ■
people, they just cannot but the food that is theoreti
cally "available".
— Of the 23 million children born every year, 2.5 million
die within the first year, Of the rest, one out-of nine
dies before the age of five and four
out of ten suffer
from malnutrition.
-- 75% of all the diseasesi in India are due to malnutrition,
contatminated water andt non-immunization.
— Only 33% of deliveries <are attended to by trained
people,
" Life expectancy' is 57 years.
is less than ceven that
in many Third orId Countries This
like; Nicaragua, Brazil,
--Vietnam, Burma, Peru etc.
_.4
9
—— 50% of children and 65% women suffer from iron defi—
ficiency, anaemia.
—— Only 25% of children are covered by the immunization
programme, 1,3 million children die of diseases which
could have been prevented by immunization.
— 1/3 of the total population of India is exposed to
Malaria, Filaria and Kalazar every year.
— 550,000 people die of TB every year.
About 900,000
people get infected by Tuberculosis every year.
——nAbout half a million people are affected with lepsory,
which is 1/3 of the total number of leprosy patients
in the world.
— 70% of children are affected by some intestinal worm
infestation.
1*5 million children die due to diarrhoea every year.
A comparison of Infant Mortality Rates (i.e. number of deaths
under the age of one month per thousand live births) of some
countries in 1960 and 1985 shows that many countries with a
poorer or comparable record 20 years back are today much ahead
of India#
TABLE
2
Country
I MR
in 1960
IMR
in 1985
Turkey
190
84
Egypt
Algeria
179
93
81
India
168
165
Vietnam
160
China
UAE
150
El Salvador
145
142
Jordan
135
105
72
36
35
661
49
Sources: *State of the World’s Children’ W87 - UNICEF.
INADEQUATE RESOURCE ALLOCATION
One of the principal reasons for the state of health of
our people, lies in our wrong priorities as far as resource
allocation is concerned. This is borne out by the following
table which shows progressive reduction in budgetary allocation
for Health in successive Five Year Plans (not inclusive of
allocation for Family Welfare)
• • •5 • • •
I
5
TABLE - 3
Plan Period
% share of Health
Budget
3.32
1951-56
1956-61
3.01
1961-66
2.63
1966-69
1969-74
2rll
2.12
1974-79
1.92
1980-85
1985-90
1.86
1.88 (esstimated)
Sources GOI, Health Statistics of India, 1984..
The government spends just Rs.3/- per capita every month
on Health.
( This may be contrasted with the estimated average
expenditure, incurred privately, of Rs.15/— per capita every
month) The following table gives a comparison of the percentage
of govt, allocation on health.
TABLE
Country
India
4
% of central govt, expenditure
allocated to health (1|983)
2.4
‘
Egypt
2.8
Bolivia
Zaire
3.1
3.2
Iran
5.7
Zimbabwe
Kenya
6.1
7.0
Brazil
7i3
13.4
Switzerland
FRG
18.6
Source: The state of the World’s Children-1987.
Moreover, even these meager resources are not equitably
distributed, 80% of the resources is spent on.big hospitals and
research institutions which are situated in metropolitan cities
and large urban centres. They cater to less than 20% of the people.
On the other hand just 20% of the resourcesis ppent on primary
health care, which caters to over 80% of the people. The following
table gives the comparative figures of hospitals and beds in
rural and urban areas.
• • • •6 • •
-: 6
*
TABLE - 5
COMPART SION OF NO. OF HOSPITAL BEDS IN RURAL AND URBAN
AREAS
(As on 1.1.1984)
No. of Hospitals % of total
No.of Beds %of total
Rural
1994
26.37%
68233
13.63%
Urban
5287
86.37%
7181
73.63%
100.00%
432395
Total
500628
100.00%
Source: Health Status of The Indian People, FRCH, 1987.
Of the total number (just over 2 lakhs) of allopathic
physicians in the country, 72% are in urban areas. Further, only
15.25% of all health personnel work in the rural primary health
sector of the government. As a result of the highly inadequate
Govt, intervention in the health sector people are forced to take
recourse to the private sector in health care. By this kind of
an approach, health has been converted to a commodity to be
purchased in the market. Only those who can afford it can avail
of the existing health facilities.
perceived by the Govt,
It is thus clear that health is
as a low priority area with grossly inade
quate resource allocation, and a skewed pattern of utilisation of
these meager resources. This is afundamental problem in the health
sector which calls for rethinking retarding the whole developmental
process in this country^
Here another disturbing trend needs to be mentioned. In the
last few years there has been large scale investment by thepriraate
sector on curative services. With encouragement from the government
for the first time in India big businesshouses are entering thefield
of health care.
In addition to the fact that they areexclusively
meant for the elite, the trend is also an indicator of a certain kind
of Philosophy within Goct. circles regafding health care. It is the
kind of thinking which draws inspiration from a World Bank report
which says "present health financing policies in most developing
countries need to be substantially reoriented. Strategies favouring
public provision of serv:ces at little or no fee to users and with
little encouragement of risk-sharing have been widely unsuccessful",
(de Ferranti, 1985). This, in other words, is a prescription for
increased privatisation. The National Health Policy Statement says
with a view to reducing governmental expenditure and fully utilising
untapped resources, planned programmes may be devised, related to
the local requirements andpotentiaIs, to encourage the establishment
of practice by private medical professionals, increased investment
by non-governmental agencies in establishing curative centres.... ir
Is this not tantamount to an abandonment of the Govt's duty in
.
7
*
•r
7 sin providing health care to all. Increased privatisation
in health can only serve to exclude the most impoverished
sections, pricisely the section who need health services the
most J. The answer to theGovt’s inability to find sufficient
resources for health programmes certainly cannot lie in
taxing the community fof provision of health care.
LACK OF HOLISTIC APPROACH
Health services, in the traditional sense, are one of the
main but by no means the only factor which influence the health
status of the people. Today the concept of social medicine
recognished the role ofsuch social economic factord on health as
nutrition, employment, income distribution, environmental sanita
tion, water supply, housing etc. The Alma Ata declaration states
"health, which is a state of complete physical, mental and social
well bring, and not merely the absence of disease or informity, is
a fundamental human right and that the attainment of the highest
possible by level ofhealth is a most important world—wide social
gpal whose realisation requires the action of many other social
and econokic sectors in addition to the health sector". Flowing
from this understa ding, health is not considered any more a mere
function of disease, doctor and drugs. Yet even today the existing
public health infrastructure in India is loaded in favour of the
curative aspects of health.
For a country like India, it is possible to significantly
alter the health status of our people unless preventive and pro
motive aspects are giben due importantte. An overwhelming majority
of diseases can be prevented by the supply of clean drinking water
by providing adequte nutrition to all, by immunizing children against
prevalent diseases, by educating people about common ailments and
by providing a clean andhygienic environment. It has been estimated
that water-borne diesases like diarrhoea, poliomyeilitis and
typoid account for the loss of 73 million work days every year«
The cost in terms of medical treatment and lost production, as conse
quence, is estimated to be Rs.900 crores—which is about 50% of the
total plan allocation on health.1
Yet according to the Govt's health policy statement (1982)
"Only 31% of the rural population has access to potable water
supply and 0.5% enjoys basic sanitation”. ^he situation is not
much better in urban slums. A recent study conducted by the
National Institute of Health and Family Welfare points out "the
existing health and morbidity patterns in theurban slums is even
worse than the ru ral areas of India". Talking about Delhi the
study says "the most important and common features in three out
8
1
>
j
4
8
out of four slums are the
extremely insanitary environmental and
hygeinic conditions in which the slum
population is living",
Further, while India accounts for
more than 35% (3000 deaths every
day)of all deaths taking place in developing
coun ries due to
’ffaccine-preventable diseases, less than 25% of
our children are
covered by the Expanded Programme of Immunization,
How preventive
measures can alter the course of diseases is typified
by Tuberculosis. Drugs for treating Tuberculosis t
were discovered after 1940.
Yet, 29 years earlier, the disease had been
J almost totally eradicated
from Britain due to improvement in conditions
of living. But even
today, when numerous drugs have been discovered
for treatment of the
disease, more thanhalf a million die of its
every year in India.
We have seen earlier that resource allocation is heavily biased
in favour of urban
areas. Similarly the emphasis on curative services also reflects a bias in our planning process in favour of such
services vis-a-vis preventive and promotive services. As in other
walks of life, health services are a function of the political system
of a community,
hey reflect the needs of the ruling sections, in
terms of resource and
manpower allocation andin regard to the choice
of technology, A holistic approach towards health care, taking in
to account the socio-economic factors influencing health, demands
of conofousness whfcb ls lacking la our plan„ing process.
PRIMARY HEALTH CARE SYSTEM
The Alma Ata Conference
defined Primary Health Care as
essential health care made universally accessible to individuals
and acceptable to them
through their full participation and at
a cost the community and country
can affort". This concept was
mooted as an alternative to the
existing concept of comprehensive
health care, which vieweed the people as
mere receivers of curative
services through doctors, health centres..
dispensaries and hospitals.
It based itself on four broad principles;
•i
1. equitable distribution
of health services.
2. community involvement
3. multi-sectoral approach
4. appropriate technology
The Rural Health Scheme launched in India in 1977 is
seen
It is
^he three
as the major component in the primary health care system,
essentially a 3-tier system of health care delivery,
levels are
1. Village level-includes
f the Community Health Worker(CHW)
scheme
and the Integrated Child :
Development Scheme (iCDsl
2. Sub-centre level-manned by one male
andone female Multipurpose
worker. Target is to have
one sub-centre for every 5000
population.
5
flI
j
I
!
-:
9
3. Primary Health Centre Level—has a staff of 3 doctors (one
female and two male) and other auxiliary staff. PHCs have
facilities for laboratory tests, minor surgical procedures etc.
They are also responsible for training of health workers, main
tenance of rec rds and for liaising with various National Health
Programmes.
While this 3 tier system is supposed to provide basic health
care, there are a number of "national health programmes".
These
cover areas requiring special attention and include areas like
Immunisation. Family Planning., Tuberculosis, Malaria, Leprosy,
Bliddness, Anild helath (ICDS)programme) etc. Thes programmes,
also known as "Vertical Programmes" are technically not port of
the Rural Health Scheme but areorganised along independent lines
with centrally administered control.
It is ’widely recognised that both the Rural Health Scheme
and the vertical progra,,es are plagued with problems of inadequate
facilities and resources. The annual report of the Ministry of
Health and Family Welfare (1987-88). very candidly states "because
pf the resource constraints only 50% of the community Health Centres
would be established by the year 1990".
In other words the
targetted coverage of the PHC system by 1990 is just 50% Similary
.is the state of various vertical programmes. The Nutrition found
ation of India in a study of the Integrated Child Development
Service (ICDS) says " Though ICDS has been extended to cover more
blocks form time to time, the support it has received has been
gruding and halting" and often "extracted after much struggle".
The CAG report for the year ending March 31, ^987, has criticised
the functioning of three major programmes viz. Blindness gpntrol
Programme, Tuberculosis control programme and Leprosy eradication
programme.
These programmes have been pulled ug fpr
improper or
non utilisation of funds, non release of sanctioned funds and lack
of planning andmonitoring of these programmes.
The principal p
problem with all the health programmes in operation has been a
total lack of community participation and the consequent absense
of accountability of theseprogrammes to the local community,
which runs counter to the cuiding principles of Primary Health
Care.
We have dealt earlier with the problem of resource constraints
and their inequi able distribution, This has its severest repercussion on the rural health scheme. Even based on &Dvt. claims the
coverage of sub-centres andprimary health centres are less than
....10....
j
-g10 s-
I
50% of the total rural population. Where these centres hsve been
set up, they are under staffed and suffer from lack of medicines
and equipment .
Miother major drawback has been the difficulty in attracting
doctors to serve in the rural health scheme. By and large doctors
opt to work in rural centres only as a last resort. This refelcts
on both the quaity and motivation of medical personnel manning
primary health centres. Unwillingness of doctors to serve in the
rural sector is also an indictment of our medical education system.
The currioulum is heavily loaded in favour of curative medicine
and within this in favour of diseases Conforming to themortality
and morbidity profile in the West. During their period of
training medical students are taught to rely on sophisticated
disgnostic aids. such training ensures that medical graduates are
ill-equipped to work in conditions prevailing in the rural areas.
Moreover the medical profession isinvested with an aura of glamour,,
which unfortunately is seen to be lacking in service in the rural
sectors.
It needs also to understood that entry into medical colleges
is by and large limited to those coming from a higher socio-economic
stratea, predominantly from urban areas, who consequently find
it difficult to conceive of working in rural areas. Even when
uneploument among doctors is not uncommonm doctors are unwilling
to take up jobs in PHCs. A two pronged strategy is required to
tackle the situation. Medical curriculum has to be reoriented
and entry into medical colleges needs to be regulated in a
manner which ensures amorebalanced “mix” of students, dide by side
incentives have to beworked out to attract doctors to the rural
health schemes. After all its is impractical to believe that
doctors
are naturally fired by
altruistic motives and with feeling of “service to the poor".
At the same time, within the medical fraternity, there is a strong
resitance in changingehthe age old concept of health as function
of doctors and drugs. Implementation of recent concept of primary
health care requi es a certain degree of demystification of
Medical Science. But within the established medical bureaucracy
and in the entrenched sectionsof the medical fraternity there is
a vested interest in maintaining the stutus quo. This outmoded
position within themedical fraternity needs to be countered.
The interaction of various ’’vertical programmes” with the
rural health scheme is another a-ea which needs attention.
These programmes are all centrally administered with seprate
administrative controls, staff and budgetary allocations.
-:11
However all theseprogrammes
need tooperate through the rural
health scheme, but
but as they have
separate administrative controls,
they are not accountable to the
rural health scheme. A'S a result
there is needless duplication
of administrative manpower, costs
and often confusion
regarding aims. While the basic aim behind the
vertical programmes of
giving emphsis to |problem areas is laudable.
they need to be administratively integrated
I with the rural health
scheme, rOtherwise, they will continue
-- ?-to wdrk..at cross putposts with
the ruraj. health
- .1 scheme, often at
great cost to the/ available material
and human resources.
i
COMMUNITY PARTICIPATION
^he slogan "Peoples'' health in people "
hands has today
received universal support. P
Diverse agencies cutting across all
kinds of ideological positions
J accept that community participation
is vital to the sustenance of ,
any comprehensive health programme,
The Govt's Statement
on Health Policy also recognises this position
while stating "Also,
over the years, the planning process hasbecome
largely oblivious
of the fact that the ultimate gola of achieving
a satisfactory health
status for all our people cannot be secured
without involving the
community int the identification of their
health needs andpriorities
as well as in the implementation and
management of the various health and
related programmes”. Unfortunately there is a basic lack of
clarity on the ceoncept of community
Participation. Often,
especially in official circles, it is taken
to imply that the
community participates in collectively receiving
health servicesA j ’
strategy developed by the Govt, to bring about
community participation
is the Community Health Worker (CHWjD scheme.
he scheme involves
ecruitment and traing of a Community Health
Workers from
every village community. The CHW is required to
interact with the phc system on fcehelf ot the viUege community
he repr sents.
e scheme was introduced in 1977, as part of the
Govt.'s Rural Health
Scheme, nased on the recommendations of the
Srivastava Committee (1975). The guidelines for the selection of
Candidates for the CHW schemes are;
1) They should bS Permanent residents of the local community,
perferably women, (in 1981 it was recommended that all
future CHWs selected should be women so that the pressing tasks
of maternal and child health may be seen to)
2) 3 minimum formal education upto Vlth Standard.
3) should be
acceptable to all sections of the community
4) should be able to
spare at least 2-3 hours every day for
'Community Health work.
...12...
X
it
-s12 5-
Candidates after selection are trained for a period of a
3 months. After completion of their training the CHWs are given
an honorarium of Rs.50 and simple medicines worth Rs.50 per
month. They are free to continue in their earlier vocation, but are
expected to devote 2-3 hours every day to community health work.
As the CHWs scheme constitutes the Government s principal
effort in implementing the slogan of "Peoples" health in peoples'
hands" it merits a closer look.
Under this scheme around 4 lakh
CHWs have been trained. However the implementation and impact of
the scheme raises a number of questions related to the whole con-
cept of community participation.
The CHWs scheme presupposes a degree of volunteerism in the
selected candidates.
Otherwise a stipend of Rs.50 per mohthis
is far short of an adequate remuneration for the CHWs whose
functions include - health education regarding preventive and
promotive measures; encouraging participation of community in
public health tasks; curative measures for treating simple disor ers
and referrals to the next level (sub-centre).
In other words the
CHWs is also required to play a leadership role in the community.
However the methodology required to identify such personsis yer to.be
In
In practice
practice the
the contradiction between inadequate remu
neration and
and high
high expectations
expectations is
is often
often resolved in one of two ways.
Either, after
short period
after aa short
period of
of CHW
CHW stops
stops performing the required
functions or dropts
r.he sets himself
dropts out
out of
of the
the scheme
scheme altogether.
altogether,
- up as a private
(In
private practicioner
practicioner in
in the
the village.
village.
tv should be realised
that the training
training imparted
imparted to
to them
them is
is often
often more
more than what a large
worked' out."
section of ungualified practitioners/guacks
tioners/auacks in villages have
t
received).
Moreover, while the CHWs main functions are related to pro
motive andpre’fQntive aspects, the village community almost
invariably is more inter sted in his curative abilities. Thus
in the village, albeit with
the CHW ends up as another practitioner
partial Government support, The training programmes of CHWs are
account regional and caste/
also not flexible enough to take into
community based differences in perceptions towards health. Thus
a dichotomy exists between the CHWs own perceptions (with are usually
closer to those of his community) and those imparted from "above"
during the training programmes.
Another misconception has been to view the rural communities
clear izision regarding
as homogeneous units. As a result there is no
vast tracts of rural
how community participation can be ensured in
caste and religion.
India which is divided on the lines of class.
.. .13....
■i
13
The tendency is to solicit support for any health programme from
the village 'sarpanch" or other infleuntial members of the village
which modtisareas means the "high" caste and landed sections. A
similar modus operand! is applied whle choosing the CHW "acceptable
to all sections" from the village community. This almost invariably
means excluding the landless and poor peasants, who form a bulk
of the population and are most in need of health services, from the
decision making process.
The dificiencies enumerated above in CHW scheme are questions
which require to be faced squarely if community participation is
to be the desired goal.
Central to theprobelem is the question
of acceptance by our village comm nities of the concept of
preventive medicine. Today attempts at intoruducing this concept
are carried out by initially gaining entry through curative services.
In other words curative services are offered as the "carrot" to
esnure to be acceptability of the programme, while preventive
services are sought to be introduced through the "back door".
Such subterfuge, which starts by not taking the local community into
confidence, cannot bring about any significant deg ^e of community
participation.
It needs to be recognised that communities are primarily
interested in curative services because of theutter inadequacy
of these services. As result this is pe ceived, and rightly, so as
the immediate necessity;.
Can the people befaulted for such a perceot
ception when majority of them are denied access to even very rudimen
tary curative services.
Moreover the functioning of programmes aimed
atproviding p reventive carehasnot shown to thepeople the advanta
ges of preventive medicine.
It is only whe, from their own experience,
people realise the advantages of preventive servicesthat one can
expect a shift in perception.
Thus to sum upz for any tangible changes to takeplace in the
field of health, radical redemarcation of priorities in the whole
health care delivery system ha e to be initiated. Hard political
decisionsto greatly increase spending on health care have to
be taken, ^or the Primary Health Care system to function adequately,
it has to be made answerable t local bodies. This in turn would
require steps to democratisethe functioning of panchayat system
and much greater decentralisat ion of administrative and fiscal
powers.
In the absense of such measure, one can only hope for some
sporadic consmetic cha ges to take place.
FAMILY PLANNING
Today urgent rethinking is required on the whole strategy
of family planning.
Expenditure in this area has increased by
... .14....
:
leaps and bounds.
14
From a meager 0.14 Crores in the First Plan it
went up to 409 Crores in the Fifth Plan, 1426 Crores in the Sixth Plan
and finally to a proposed 3256 Croces in the Seventh Plan. Yet the
birth rate has remained static at around 33 per 1000, for the last
decade.
How then is the continued increase in expenditure on family
Planning to be justified?
Actually the basic problem lies in the inverted logic that
a
falling birth rate preceds socio-economic development. The
experience in countries all over the world has shown that exactly
the reverse is true. The family planning programme as it stands
today, is another example of attempting to find technological
solutions to social problems which require societal measures.
Moreover, the family planning programme with its fetish for targets,
places an added burden on the health care delivery network, which
it is ill equipped to carry. As a result there is a further
whittling down of the already meager relief that the primary health
care system provides.
As noted in the case of other vertical
programmes, the family planning programme too needs to function in
an integrated manner with the rural health scheme.
CRI SI 5 IN PHARMACEUTICAL INDUSTRY5
Though there continues to be a greater emphasis on the curative
aspect of health even this area is plauged by a variety of problems.
This is examplified by the total anarchy which prevails into the
production and supply of medicines.
Only 20% of the people have
access to modern medicines. There are perennial shortages of
essential drugs, while useless and hazardous drugs flourish in the
market. There are 60,000 drug, formulations in the country, though
it is widely accepted that about 250 drugs can take care of 95%
of our needs. The market is flooded with useless formulations like
tonics, caugh syrups and vitamins while anti-TB drug production is
just 35% of the need. While 40,000 children go blind every year
due to Vitamin-A Deficiency, Vitamin-A production was just 50% of
the target in 1986-87. The production of Chloroquine has shown a
decline in recent years, at a time when 20% of the people are
exposed to Malaria every year.
Globally the Pharmaceutical Industry, is today a live topic
for discussion. On the one hand new vistas are opened up everyday
and new drugs have revolutionised treatment of several diseases.
Side by side, increasing concern is being expressed about the
harmful consequence of the unbridled growth of the Industry. The
....15/-
15
turnover of the Pharmaceutical Industry has increased by leaps
and bounds and today/ globally, it stands next only to the
Armaments Industry. The growth of the Industry has been
phenomenal in India too. From a turnover of Rs.10 crores in 1947,
it rose to Rs.1050 crores in 1975-76 and today stands at
Rs.2350 crores.
In spite of the growth in Pharmaceutical production in the
country, however, morbidity and morality profiles for a large
number of diseases continue to be distressingly high. It is thus
clear that there is a dichotomy between the actual Health “needs"
of the country and drug production. It is also obvious that a mere
arithmetic increase in Drug production cannot ensure any significant
shift in disease patterns. •. Hence, if this dichotomy between drug
production and disease patterns is to be resolved, some drastic
measures are called for to change the pattern.
The Pharmaceutical Industry in India has developed along the
lines followed in developed countries. The reasons for this are
twofold. First, the Industry in India being in the grip of MNCs,
drug production has naturally followed the pattern of production
in the parent countries of these MNCs. No attempt has been made to
assess to actual needs of the country. Secondly, the India/Drug
Industry caters principally to the top 20% of our population, who
X
T
have the purchasing power to buy medicines.
his is also the section
which is amenable to manipulationsby the high power marketing strategies
of the drug companies. Moreover, in this section/ disease patterns
do roughtly correpondent to that in developed countries, The
industry is thus able to nreglect the needs of 80% of the population
andyet make substantial profits, *t sees no ned to change its pattern
of drug production and thrust of its marketing strategu. One is
unlikely to see any change in these areaes unless the industry is
compleeled to change by stringent regulatory measures, by the ov
Government.
Further, drugs differe from other consumer goods, in that
while the consumers have a direct say in the purchase of consumer
goofd, such is not case for drugs. Drugs are purchased on the
advice of doctors, Even in the caseof over the counter sales of
drugs, doctors and chemists have role in determining themarket
needs.
The prescribing habits of doctors are determined initially
by the curriculum of medical education and later by information
supplied through medical representative by drug companies, Medical
students are trained on the lines, followed in the west, and by and
...16....
-? 16 s -
large the curriculam has very limited relevance to the existing
situation in the country. On this the report of the Medical
Education Committee, Ministry of Health and Family Welfare says.
The present system of medical education has had no real impact on the
medical care of the vast majority of the population of India”. It
is thus the not suprrising that what doctors prescribe have little
relevance to the disease patterns in the country.
what is probably even worse is the fact that doctrs,
after
passing out of teachinginstitutions, have almost no access to
unbiased dnug information. As a result their prescribing habits are
moulded by information regularly supplied by drug companies.
his information for obvious reasons, is manipulated to support the
production pattersn of the drug industry. 6o ulti tely what
medicines the patients gets is determined not by his actual needs
but by what the drug companies feel are necessary to maximise their
profits.
INCORRECT PRIORITIES OF GOVERNMENT
The problem is compounded by themanner in which the government
makes estimates for drug requirements.
1he most important criterion
used for this purpose is based on 'market needs'. Given the scenarie
related above, this can nevef reflected the actual drug needs of the
country.
- Today, a need is created forvariovs inessential durgs,
by salves prmotion campaigns conducted by drug companies. ihus for
ecample Vitamins and tonics in large doses are prescribed laon.- with
antibiotics. This is a 'created need', though Vitamins and tonics
are sameof thehighest selling products in themarket.
India accounts for about
of the world's population, many-
factures andmarkets only 2% of the total global drug production,
out of which barely 30% are essential, to meet the drug needs
to drug to treat 24% of the total global morbidity. Thef ollowirg
table gives us some idea of the shortfall in essential. drug production,
(Though the gravity of the situation ismore than waht ■
the table indicates, as the demand estimategiven for 1982-83-based on governmert
figures are a gross under estimation. Moreover for 1986-87 the
Chemicals Ministry has even stopped giving gurues for demand esti
mates, and supplies only figures fortarget of productionJ '
TABLE - 6
SHORTFALL IN PRODUCTION OF ESSENTIAL DRUGS
1982-83
-.71986-87
Name of Drug
Unit Demand^TotalAva Target TotalAva
EStimace?lability Estimate liability
Penicillin
MMU 370
360-32
450
266.64
Streptomycin
T
270
247-87
270
203.88
....17...
Chloramphenicol
Ampicillin
Vitamin-A
T
300
111.46
300
71.60
200
MMU 77
142.27
52.00
380
140
158.45
188.59
177.61
T
69.34
INB (anti Tuber
cular)
T
250
288.30
Chloroquine
T
200
194.57
325
410
Dapsone (Anti Leprosy)T
200
86.90
60
25.51
Diptheria Anti Toxin MU
800
6 53.57
800
691.05
Sources Indian Drug Statistics, 1984-85 Ministry of Chemicals and
Fertilizers, (GOI. & Annual Report Department of Chemicals
and PetrochemicaIs, GOI, 1987-88.
The Indian sector in the Pharmaceutica1 Industry(including
both private and public) has the capability to produce all
essential drugs. Yet the multinational sector continues to play
a dominant role.
he mercenary attitude of drug multinationals is
responsible for holding the health of the country to ransom.
They
market drugs in this country which arebanned in their parent count
ries.
They use the country to test new drugs with dangerious side
effects and in a variety of ways flout the law of the land with
inpunity. Health related industry has the second largest turnover,
owlr over, after the armaments industry. Today the predatory nature
of thepharmaceuticaIs industry appears ready to outstrip even the
arnaments industry.
he conctol of drug multinational companies on the L
the Indian market is alsmot complete. There are more than 50 MNCs
in the drug market in India. ±ifteen such companies control as mnah
as 31.8% if the total Indian market.
MNCs in theprocess have earned
huge pr 'fits while charging exorbitant prices for their products.
There have been persistant demands that the Multinational
companies should be nationalised. In fact this was one of the
recommendations of the Hathi Committee set up in 1974 to go into
the problems of the Pharmaceutical Industry.
MNCs are still being
allowed to operate in this country on the plea that they’bring in
new technology. ^ettheir record in the last decade shows that their
contribution in this field has been less than the Small Scale Sector.
Today the MNCs reap super-profits by mainly producing inessential
drugs. -‘■he following table gives an account of the contribution of
MNCs in drug production.
....18....
-:18s -
TABLE-7
C0MPARA1IVE CONTRIBUTION OF MNCs AND NATIONAL Cos
. (Top 85 Cos.)
Class of Drug
Total prod.-
ESSENTIAL
(Rs.in Crores)
MNCs (40)
National (45)
Antibiotics
Anti-T.B.
256.5
82.9
173.6
29.2
Anti-T.B.
29.2
(32.3%)
4.0
(6 7.7%)
25.2
Sera—Vac cknes
1.5
0.5
(33.3%)
Coudjh&Cold
32.0
55.7
20.1
(6 2.8%)
41.4
(74.3%)
Preparations
Rubs &Balms
12.5
12.3
(98.4%)
1.0
(66.7%)
INESSENTIAL
SIMPLE REMEDIES
Tronics
11.9
(3 7.2%)
14.3
(25.7%)
0.2
(1.6%)
Vitamin
98.0
78.8
19.2
(80.4%iD
(18.6%)
Sources ORG Retail Survey/ April 85 to March 86.
The new drug policy announced in December 1986,
instead of
spelling out measures for control of MNCs has granted
them even
more concessions, ^t has allowed increased profitability on
drugs and has reduced production controls. T
he recent trends of
import liberalisation and peoduction and price decontrols are in
line with the present "over ments attitude to industry as a whole,
However the drug industry is probably unique in that it has adirect
bearing on the lives of almost
almost everyone,
everyone. The government has never,
while formulating its drug policy. takenitbo account this uniquences.
As a result ''market"forces" are being allowed to determine the
In aa situation
situation w ere only one out of
In
following a policy which is detrimental to
to the
the interests
interests of
of an
availabilty andprices of drugs.
overwhelming majority of people.
ROLE OF VOLUNTARY AGENCIES
Probably the single largest contingent of Voluntary agencies
are involved in work in thehealth sector. Unfortunately thenet output
of their work has not been commensurate with theextent of their
One of the major problems has been themultiplicity of
agencies thus involved and the r consequence inability to come up
with conherent outputs. 1’he d verse ideological andmethodologica1
presence.
predilections of these aencies ha e also prevented then from arriving
at any kind of unified understanding. Many a encies are dependent
...19...
19
%
are depedent on the quality of those heading such projects, which
ultiflaatoly works as a constraint in replication of pioneering
efforts in different conditions. Moreoverthe need to develope
models for replication are not recognised as a priority by most.
These problems are often compounded by the mtItip'licity of dunding
agencies, each with differing perspectives• This results, at times,
in agencies having to modify their outputs to suit the needs of
funding agencies.
Compared to Government services the coverage by the Voluntary
sector in providing primary health care is negligible and will remain
so indeed, the basic responsibility forhealth care must rest only
with the state.
ence the contribution of the V’oluntary section in
India needs to be assessed in terms.of the kindof innovative ideas andpre
programmes it has been able to throw up in thelight of its experiences.
With the voluntary sector three broad trends can be identified.
ome
agencies are engared primarily in providing curative services.
There are others who have attempted to imp&nented the concept of
Primary ealth Care by also inclduing programmes aimed at community
participation and preventive care. ** third set has taken up broader
issues like land relations, agr cultural wagesm power structures
in villate communities etc. in addition to health issues.
The latter two trends have come up with alternate models for
primary health care. Unfortunately very f of them aresuch as
can be replicated under different conditions all overthecountry. The
reasons for this are many, but some may be highlighted. Most
a gencies depend heavily on the drive and initiative of 2-3 indivividls. As replicability is not seen as a priority little thinking
has gone into formulating strate ios that do not depend on the
quality of a 2-3 project leaders. The costs involved, sources of.
funding and their impact on replicability ha >e also -not been
worked out. Another notable trend is that, in looking for alternate
modesl, emphsis has been on "parallel" structures andmechanisms
outside the state run PHC structures—i.& the outlook is to build
new structures to by passor even run counter to the existing health
delivery network, ^or
'or nationwide impact, such an enterprise would
neither be successful nor desirable. further, such fundamentally
differently structures may in fact be envisaged only under alter
native socio-economic structures and this, of course, is why the
need is felt by somehealth groups to engage themselves in taking
up socio-economic issues also*
gSM organisations, too hold that fundamental socio-economic
transformations are necessary for a rational health policy and,
in general, for benefits of science&technology to be socially
equitable. But, rather than wait for these transformation or working
....20...
I
-:20sin the purely socio-economic political dokain, PSMorganisations
work both to promote greater consciousness about the issue and to
creat working “models” -i.e. viable and replicable structures with
the potential for becoming nationwide alternative policies and
implementation mechanisms. In the health sector, as perhaps in
education too, this would necessarily involve working, in a broad
sesnes, within existing institutional&other structures and looking
for alternative models&mechanisms for the State HeaIth'-DeLfcvery
System, with well-defined roles for PSM and other peoles* organi
sations.
ROLE OF AIPSN
The AIPSM has the potential forintervening in a meanginful
way in the health sector. xt has thetwin advantage of having an
All India reach and a relative homogeneity of purpose and approach.
There is also the in-built scope for exchange.of views among
constitutent organisations. Moreover already existing linkages
with organisations of medical and para-medical personnel can be
strengthened.
uch advanta es confer on the AIPSN the necessary
impetus to overcome many of the shortcomin s of voluntary agencies
cited above. The broad direction of AIPSN's involvement in healt h
should be along the following lines:
__ Policy issues: Work out its perspective on Health Policy, Drug
Policy etc. A campaign aimed at the policy makers can be
planned based on this perspective.
—Mass ca,paigns: Based on the AIPSN’s basic understanding
regarding health some fundamental demands need to be formulated.
These can be taken up as campaign issues among the general
public. Given the nascent stage of develppment of the Peoples
Science Movement in most stages, the campaign should be focussed
on a few key demands.
—— Linkages with health delivery personnel: Lingages need to be
built with organisation of doctors, para-medical personnel,
medical representatives etv. Such linkages can work also to
attract these sections, involved in health care delivery, to
the Peoples Science Movement.
Models ofor Primary Health Care: Initially in a few selected
areas the AIPSN should develop models for Primary Health Care..
Based on the experience gained strategies for replication can be
worked out.
....21...
*
-:21s-.
■
The most probelematic area in the Health Care Delivery
system in the country is the interface between the PHC system
and the users of this system i.e. village communities. The
AIPSN can have a major role to play in this area. *t can play
the catalysing role in making the PHC system more answerable
to the community. It can also work towards sensitising communi
ties to issues to issues related to health, so that instead of
being passive receptents of Government servies they can involve
themselves in the decision making process. Such interventions
also require demooratisation of the political and administrative
set up, with much greater powers being reserved for local
b odies right down to the panchayat samities. flere a^ain the
AIPSN can play a major role in association with local democratic
organisations of thepeople. Given such a perspecpective the AIPSN
with its All India reach, is in a position to work out models for
primary Heaith Care whlch can bg replicated gll Qver thg country.
Reference
Debabar Banerjee t Health and Family Planning Services
in India;
Pub,Lok Paksh, 1985.
Health Care Which Way to Go; Medico Friends Circle.
Statement on National Health Policy;Government of India, Ministry
of HeaIth&Family Welfare, 1982.
Health for All, an Alternative Strategy? ICSSR&ECMR, 1983.
Drug Industry And The Indian Peoples DSF&FMRAI, 1986.
H ealth Status of the Indian Peole: Foundation of Research in
Community Health, 1987.
State of the World’s Children, UNICEF, 1987.
Meera Chaterjee, implementing Health Policy: Manohar, 1988.
J.E.Park, Text Book of Preventive and Social medicine; Pub.
Banarsidas Bhanot, 1986.
*****************
o m H-f1 '
an
OVERVIW OF DIFFERENT COMMUNITY HEALTH PROGRAMMES IN INDIA
(MODELS AND APPROACHES)
I. IOTRODUCTION-
Community health approach to health care has been widely reco
gnized as the right alternative for ensuring health to the poor
millions in developing natives. In India too, governmental as
well as voluntary efforts are made for the promotion of
community health. In the evolution of health care system, this
approach has emerged through a process of dialogue between the
medical and the social sciences in an effort to make the
health care system relevant and responsive to the sociopoliticao- economic realities in the society. Again, in the
precess ofevolution and formulation of community health in
terms of its principles, philosophies and methodologies, various
models have been proposed and practised. In this paper an
attempt is made to categorize these models into four, each with
its wn characteristic features.
Further, eadh model with its characteristics could be explained
as following a certain approach in community health. These
approaches are broadly divided into three. An understanding
of these three approaches could give us a frame work to assess
as to which approach each models follows. Another interesting
correlation is that each of these three approaches reflects
a certain philosphy of development work.
In the following paragraphs an introduction is made into such
an analytical overview. In the latter part of this paper the
four models with their characteristics are listed out. Under
each model, the particular approach into which it fits into
is also given with certain indicators or assessment.
II.
DIFFERENT MODELS IN COMMUNITY HEALTH
A study of the ongoing projects and the 1 iterature available
on them reveals that m India theae exists different models/
types of commuhity health products. They fall under four
major categories. Each one is run by differ ent types of insti
tutional set ups as big hospitals, small hsopitals, rural
dispensaries, or run by non structured voluntary health/ action
groups. Again, each model is unique in terms of infrastructure,
services rendered, needs met,and the results achieved. It
would be clear from the forthcoming table.
III. DIFFERENT APPRQACHESIN COMMUNITY HEALTH.
Three approaches have been identifyed in community health.
They are : Medical approach, health extension approach,
Comprehensive approach.
Considers health as the absence of
diseases brought about by medical
interventions based on modern sciences and technology and sees
the role of the community(the people) as responding to the
directions given by the medical professionals. It has its
roots in the medical model of health care .which b elieves t&rt the
eradication ofiill-health depends on doctors and medicines.
(a).
Medical approach;
approach
Based on a< critique of medical
approach. It accepts WHO
def enition ofhealth as the total physical, mental and social
well being of the individual.
Mere advancement of medical
(b) Health extension ap-roachr
2
technology and the sophistication of serviceweuld not bring
health bo themajority of thepcorle - especially the poor - and
that tne, approach should be a" planned redistribution of health
care facilities to reach the vastness of the society. The
approach also advacates other socio- economic uplift programmes
to enable people to benefit from health care facilities.
Preventive core is also emphasized.
(c)CComprehensive approach:
Views health, the concept of
total well being in the context of
the situational
realities of the individual. This' concept
is_ elaborated by stating that health, the state of tdnl well
being, is also a human condition which does not improve either
by providing more services or mobilizing the community for
providing more health services. It improves only by having the
community take control and responsibility for decisions about
Gf.o how tomobolize , utilize and distribute services and resour
ces. Here community is thesubject, decision maker, It is a
process of conscientizationf organization and capacibation of
the conimunity for action, it has bearing on the social,
economic,political andcultural dimensions of human life, in the
scnce that the approach strives to bring about changes in them
so that there would emerge a society whete human life would be
more healthy in the complete sense of the word.
IV.
COMMLWITY HEALTH AND THE DIFFERENT APPROACHES IN
DEVELOPMENT:
’ ’
- -----------------------
Development work is bsused. on certain analysis of the hackv/ardness
of the people. According to the analysis , different philosophy
of development
A vork
n are arrived
I - ’ at.
L. They are mainly three
approaches: J'
Modernization approach,?.welfare apprea.ch, and social
justice approach. In the context of sneaking about different
approaches in community health work , it w? uld be worth mentioning
these approaches. It is interesting to note that reflections of
these approaches are found in the three community health
approaches
(a)
Themodernization approach analyses poverty as the lack of
enough production and itmakes efforts to gear up product! n
through advancede, technology in the field of agriculture and
industry. It believes that the result of modernization would
trickle down to the lower strata of society.
(b) The welfare approach recognizes different classes and castes
existing in the' society. It is due to the co-existence of
development and under development in the society. This state
is accepted as a normal reality. Efforts are made to alleviate
the sufferingseof the poor.through organizing relief and
charity work. People are passive receipisnts here. Recently
there has been some changes in this approach and it recognizes
the participation of the people and the mobilization of their
resource. Programmes also have improved remarkably from
relief work to development programmes aimed at the uplift of
the poor. through income generating programme, literacy
programmes, vocational training etc. Tfteb poor continues
to
exist and the disparity between the riefe and the poor also
continues as a reality. Statusquo is not disturbed.
*Conscientization isnan awakening of consciousness, the
development of a critical awareness of a person’s on identity
and situation, a reawakening of the capacity to analyse the
causes and consequences of one’s own situation and to act 1
logically and reflectively to transform that reality”
(David Millwood)
-.3/-
- 3 c*
In social justice approach a critical*analysis of the
society is employed and poverty and bacInwardness are under
stood as man made historical reality. The reasons are
attributed to the -various forces and the dynamic at work
in the society. Poverty is precipitated as a result of
injustice. Justice could be brought in only through a
restructuring of the society. It could be achieved
through empowering the people through awareness building
and organization. Ultimate development of the poor would
mean fair distribution of the means of production, living
wages, consumption of good food, availability of public
amenities, practice of human values as love, cooperation
and unity.
It becames clear that the analysis and approaches of
development work has correlation with that of community
health work. Characteristics of modernization approach are
reflected in medical approach and features of welfare
ap-roach find expression in health planning approach, Social
justice ap-roch goes well with, comprehensive approach
in terms of its analysis and approach.
V.
THE FOUR MODELS AND THREE APPROACHES
IN COMMUNITY HEALTH
As mentioned alreadyythe community health programme existing
in the countty could bo classified into four based on the
characteristic. The following table would give that.
Under tach ;rogramme a note is made as to which approach of
community health it belongs to. To make it clear six
indicators -are given based on which thisc- assesment
is made. Those indicators are: role of health services,
role of professional, role of community worker, Community
participation,evaluation and financial support. For each
approach these indicators show different explanations.
MODEL
A jCHARACTERISTICS
I.
Nature of -Services
Rendered
Type of institution/
infra structure
Capital intensive, highly
sophisticated and insti
tutionalized big hospitals
Mobile medical team with
doctor a medicines.
o
- ExtensiSU service from
hospital.
- Curative care.
- Running village clinics.
- Referral service, free
medicines.
- weekly or fortnightly visits.
Neec$ met
Result- Qualitative changes.
Treatment of minor
physical ailments.
- People become more conscious ato
sickness and medicines.
- more patients in the hospital
- feeling of dependence in the
people, demanding free services.
- shift from home remedies and
indigenous medicines.
Referral and free
transportaion to the
hospital,
THE APPROACH ROLL WED.
The approach followed is medical approach,
assesment on that.
'
The following are six indicators vhich would help us to make an
Indicators
Explanation.
a. Role of health service
b. Role of Medical Professional
- means to improve the health status of the people
- Key to the programme- manager, planner,9 problem solver, coach. consultant,
clinician, leader, teacher, evaluator.
- a means by which medical advances could be applied more rapidly and
effectively.
- a means to ensurearnere-acceptibility and utilization of services.
- Based on analysis and interpretation of statistics which reflect the scope
and results of applied medical science and technology.
- needed to create,7 expand and maintain the service.
c. Role of community health worker
d. Community participation
e. Evaluation
f. Financial support.
MODEL . II
A. OHAP^CT ERIST ICS
Needs met
Results- Qualitative changes,
Type of institution/
infra str uc t ur e.
Nat ur e of s ervi ? e s
r end er ed.
Capital intensive, sophi
sticated and institutiona
lised small hospitals.
- people meeting in groups.
- Extension services.
- Treatment of minor
- learn some preventive methods.
- curative and preventive
ailments.
care.
- More patients in the hospital
- Referral and free
- Village clinics
- Learn that they can do something
transporation
- Referral services.
about health.
to the hospital.
Medicines at reduced
- personal and environ-*
rates.
mental hygeine.
- weekly or fortnightly
visit'S'.' • ■
_
- HSalth Education
- MCH programmes/ immunization.
- Village Health Workers with
medical kit,
Medical team with
without doctor.
or
B.APPROACH FOLLOWED
The approach followed is Medical approach. :But there are certain changes, in the sense that it is not strictly
Medical approach. There is an indlinatimtowards Health Extention approach.
Indicators
Explanation.
a. Role of health services.
b. Role of medical professional
- Means to improve the health status of the people.
- Medical professional c ontinues to be the key personnel, But, para medicals
gain a role here.
- along with being a person to ensure more community acceptability for medicine ,
CHW also imparts preventive health education.
- a means to ensure more acceptability to medicines as well as a means to
disseminate ideas of preventive health education.
- based on analysis and interpretation of health statistics that shows the scop
and result of applied medical science as well as the effectiveness of prevent
health education.
- needed to create, expand and maintain the service.
c. Role of Community Health Worker
(CHW)
d. C
unity,participation
e. Evaluation
f. Financial support
'MODEL
III.
Type
institution/
Infra s truc t ur e7
A. CHARACTERISTICS
Needs met.
Nature of services
rendered.
- Better environmental
-Preventive, promotive
Rural health centres
sanitation.
and curativeo
manned by nurses, not
institionalized, :still very - Community health workers - M.C.H. Services,
- Supplimentary income
with simple medicines.
much st r uc t ur ed.
for a section of the
- Health education, Adult
population.
Education
A team composed of a
- Smallincome generating
nur s e and social
proj ecta
workers.
- kitchen garden
- M C H
- Collaboration with govt
and other agencies.
- village meetings and
discussions on different
village problems.
- promotion of collective
action.
Result - Qualitative changes.
- people become aware of the important
of preventive medical care.
- Less patients to go. to the hospiti
- Better child care.
- people try to see health in relation
to economic backwardness.
- Develop more interaction among the
villages, formation of small infer?
gr oup s, mahilamand als.
- peopleoecame aware of their collecti
strength.
B. APPROACH FOLLOWED.
The approach followed is Health Extension approach. The following indicators would make it clear.
Explanations.
Indicators.
a. Role of health services.
b. Mole of medical professional
c. Role of Community Health Worker
as it vews that good health is the result of planned health services,
experts from other fields as economists, social workers, etc- are a?so
involved to make services effective.
- The medical professional is viewed as a component rather than key. Fnrth> v.
experts from other disciplines are also involved - economists, soci* 1
workers, etc. Attempts are also made to include community leaders.
- CHW is considered as an agent of change - and works as a multi purpose w
worker which include medical services, prevention, public health work, h
education, nutrition education,
education food production and housing improvements.
THEL
THE LANCET, JULY 5, 1986
•30
/____
waso
wasfc
follow
were
pracc
comp
trans;
comr
visile
’ i or death occurred
evidence that systemic dissemination
earlier in the interval cancer group. Thus growth rate of
the primary tumour may not be a true indication of the
rate of systemic progression.
Growth rate is determined by factors such as cellular
A HEALTH VISITOR AFFECTS THE
regeneration, death and migration, resting-cell fraction,
PROBLEMS OTHERS DO NOT REACH
hormonal influences, nutritional aspects and host-tumour
reactions, and may not be accurately reflected by
measurements such as radiological tumour size or fraction of
Norman J. Vetter
Dee A. Jones
dividing cells in tumour specimens.
_r--'
• Widely accepted
Christina R. Victor
biological theories on tumour progression and behaviour of
Research Team for the Cart of the Elderly,
subclones of tumour cells also indicate that the process is
University of Walts College of Medicine, St David's Hospital,
highly complex and involves many dynamic changes.
Cardiff
Furthermore, there is evidence20 that even different'
■
r
rates,
merasrases in the same individual grow at different
relation between growth rate of the primary
Difficulties associated with old age that
Summary
tumour and its meustatic potential has not been clearly
were previously unknown to the general
established.10 Our study contradicts the hypothesis that
were
detected by a health visitor attached to a
in interval cancer than in breast . practitioner
the prognosis is worse L.-------general practice for 2 years and given a case-load of 296
cancer diagnosed in an ordinary clinical setting.
-3 or more. Previously unknown
people aged 7C
70 years
Nor do our observations support DeGroote and
conditions included physical and mental illnesses
SS; "reia^ to the patient’s environmental setting or
.leagues’ suggestion of aggressive management of
'(^^ho^ked’after the
interval cancer.6 In their study the difference in
to the person (carer) who looked after the patient regularly.
prognosis between interval breast cancer and screenMost
of the severe illnesses were
known to the -general
1VIU3>L Vi U1V
--------- ---detected cancer was not statistically significant.
practitioner but many minor ailments and other aspects oi
Moreover, the screened population was heavily
old age were not. Even
——though
----- «—the .practice had a policy of
influenced by self-selecuon.21
encouraging doctors to visit the elderly in their homes, the
health visitor was more successful at obtaining a complete
Correspondence should be addressed co L. H. H., Department of Surgery,
picture of old people’s home circumstances and the
Central Hospital, S-791 82 Falun, Sweden.
consequences of them.
Community Health
A a*
I
ii
bea
resii
sect
asse
wer
476
mo:
3
assc
ye
t
th<
dr
fell
pai
mt
fre
thi
H;
of
wi
INTRODUCTION
1 vFounucrD.WeberE,HoetoW,KubUF.BanhV.GrowthrauofUTnwnnwy
Z
™ HC
Budwup
lusoaadon of pathologic and mammographic charactensna of primary human
breast cancm wuh “slow” and “W growth rates and with axillary lymph node
rrwratraws C.arte^T 1984; S3:96-98.
.
f
3. Charlson ME, Feinstein AR. A new clinical index of growth rate in the staging of
breast ranerr Am J Mtd 1980; S3t 527-36.
4. Boyd NF, Meaiung MW, Hayward JL. Clinical eaumauon of the growth rate of breast
cancer. Concur 1981; 48: 1037-42.
5 Pearlman AW. Breast cancer-influence of growth rate on prognosis and «aun«
evaluauon: a study based on mastectomy scar recurrences. Cancer
Wi
DecXte R. Rush BF, Mrlazzo J, Warden MJ. Rocko JM.Interval(breast cancer: a
more aggressive subset of breast neoplasias. Surf my 1983,94: 543-47.
7. Kuum. S, Spnn JS, Don^»n WL, W.«» FR,
p™, n«e
growth of human mammary cardnoma. Cancer 1972, 3(h 594-99.
B.Tubiana M, Malaise EP. Growth rate and cell kmencs in
prognostic and therapcuuc impheauons. In; Symington T, Carter RL, eds.
Soenufic foundations of oncology. London: Hemenann. 19769. Steele JD, Buell P. Asymptomatic pulmonary nodules. ] Thaeac CardwvaiC
rj
1973 65* 143-51
10 Sugarbaker EV, Wingrad DN, Roseman JM. Observation* on cancer metastasis in
man. In: Liona LA, Hart IA, eds. Tumour invasion and metastasis. London.
Martinus Nnhoff, 1982.
xaa_ad
11. Love RR, Canull. AE. The value of screening. Cancer 1981; 48: 489-*k
12. Tabar L, Gad A. Screening for breast oncer: the Swedish tnal. Radiology 1981, 138.
13. Ta^L^Fagerberg G, Gad A, et al. Reducuon in morubj, from breast cancer after
mass screening with mammography. Lancet 1985, i.
14. International Union Against Cancer. TNM elassifleauon of malignant rumours.
15. Ma^d^EviSo^of survival data and two new rank order statistics arising in its
consideration- Cancer Chemother Rep 1966, 50: 163-70.
16. Cox DR. Regression models and Ide tables (with discussion). J R ^at Soc
>».
187-202.
r
17. Shapiro S, Venet W, Strax P, Venet L, Roeser R. Ten to fourteen year.efTect of
Mjeerung on breast oncer mortality. JNC/ 1982; 69: 349-55.
18. Nowell PC. The clonal evolution of tumour cell populations. Science 197b,
i
19. Fidler IJ, Hart IR. Biological diversity in metastatic neoplasms: origins and
ixnpbcaoons. Scitnct 1982; 217:998-1003.
20. Spran JS» Spran TL. Rato of growth of pulmonary metastMC* and host survival. Am
21. Rater U4. Breast oncer dexnonstranon proiecu Five-year summary report. CA 1982;
32:194-225.
Many workers15 have shown the importance of unso
licited visits to old people at home. About a third of the
elderly’s needs and disabilities are unknown to health or
social services personnel. This may be because old people
have poor expectations of their health or because they may
fear being taken into residential care or hospital if they
appear to be incapable of coping. A further factor may be
that seeking professional help was formerly regarded as a
luxury, for emergencies only. Thus relatively minor chronic
illnesses/ailments are left unpresented and therefore un
treated. A view has emerged that favours routine and regular
visits to the elderly.
The health visitor is well qualified to undertake this kind
of work,'and many have shown great skill with old peopk.
There are drawbacks, however: health visitors regard child
welfare and maternity work as their priority and not all will
take an enthusiastic interest in the elderly. Because of
shortage of staff in some health districts it may be impossible
to devote suffident time and energy to the demanding
requirements of case-finding in the elderly. Nevertheless, if
regular visits are the best means of improving the quality o
life for old people, health visitors are the only professional
group likely to take on this kind of work.6*’ This study was
undertaken to examine the work of a specialist health visitor,
in a general practice, with a case-load of people aged over 70
years.
METHOD
A random sample of 296 practice pauents aged 70 years or more
(about a quarter of the total number in this age group in the practice,)
was assigned to the health visitor for 2 years. The health visitor was
instructed to give a major check-up annually to all her panents. She
Bli
nil
be
fo:
..a
in
i
I
i
i
IT
ai
si
1
THE LANCET, JULY 5, 1986
31
was expected to visit more often if necessary or if one of her patients
was found to need help by another member of the practice. She also
followed up any difficulties identified at the annual visit. Patients
were interviewed and notes taken according to usual health visiting
practice. In addition, a problem sheet and procedure form was
completed at each interview. The information thus obtained was
transferred to a card in the patient’s practice notes, to help
communication between the general practitioners and the health
visitor.
RESULTS
In the first year 32 of the 296 subjects were not included
because they died, moved out of the area or moved into
residential care. A further 11 people were lost during the
second year, mainly because they died; thus 253 people were
assessed during the second year. In the first year 264 patients
were visited on 451 occasions and in the second year, 253 on
476 occasions. Thus despite the reduced number of subjects
more visits were made during the second year.
Table I shows the number and type of difficulty, as
assessed by the health visitor during the first and second
years. In the first year 21 individuals had no difficulties, and
a total of 774 were identified in the remaining 243 people.
According to our classification the majority of problems
were physical in both years. The next most common
difficulties were environmental, and then those relating to
carers. There were 51 categories of physical illness, of which
the most common were those attributable to diseases of the
circulatory system. 46 of the problems during the first year
fell into this category. The next most frequent were joint
pains (43), followed by difficulty with eyesight, other
musculoskeletal problems, and trouble with feet. The most
frequent mental condition was reactive anxiety (about a
third), followed by reactive depression, and memory loss.
Half of the social problems were attributable to an inability
of the patient to leave the house as often as he or she would
wish and most others to family rejection. Most environ
mental problems concerned housing: the expense of run
ning a house, maintenance, and repairs. The financial
burden was sometimes great because the house was too large
for the elderly person. Also important was the difficulty
caused by isolation from shops. 31 (67%) of carers’
problems in the first year were related to the age or
increasing frailty of the main carers.
The general practitioners’ knowledge of the difficulties in
individuals was assessed by examining the practice notes
and questioning general practitioners on each case. Table n
shows that in the first year the general practitioners were
TABLE II—HEALTH VISITOR S ASSESSMENT—ACTIVE PROBLEMS
PREVIOUSLY DETECTED BY GP
Type of problem (°0)
Physical
Mental
Social
Environ
mental
Carers
Total
414(7(7)
181 (30)
22(67)
11(1?)
4(//)
32(89)
5 (8)
59 (92)
16 (55)
30(65)
461 (60)
313(40)
Knowledge
ofGP
First year
Known
Not known
Total
problems
Second year
Known
Not known
Total
problems
595 (,100') 33(100) 3f>(100) fA(lOO) 46(100) 714(100}
63 56
50 44
5 33
10 67
2 25
6 75
2 8
24 92
9 35
17 65
81 43
107 57
113 100
15 100
8 100
26 100
26 100
188 100
aware of 60% of the problems detected by the health visitor
overall. The majority of the physical and mental problems,
but only a small proportion of the social, environmental, and
carer difficulties, were known to the doctors. Despite the
presence of the health visitor this proportion decreased
during the second year. Difficulties caused by feet were the
most commonly missed by general practitioners: in the first
year, of the 34 affected people doctors were aware of only 4.
Two other important areas were poor eyesight (15/36
detected) and hearing (12/29 detected). Frequent falls and
severe incontinence (in this study there were 10 females with
stress incontinence of whom 5 were known) were also
sometimes unknown to the general practitioners. These
findings would be inaccurate if, for example, the doctors
took poor notes or didn’t remember very well. This seems
unlikely, however, since the same methods showed that
nearly all illnesses of specific organs were known to the
general practitioners—eg, 45 out of 46 people with active
cardiovascular disease. The 4 patients with severe endoge
nous depression were also known to the practitioners.
Environmental problems attributable to inaccessible
toilets, upstairs bathrooms, or poor housing conditions were
all poorly detected by general practitioners. The difficulty
some had in getting to the doctor was also largely unknown.
Instances where the main carer was old and disabled were
known to the doctor in 10 out of 29 cases.
During the first year an independent assessment was
made of the severity of the cases before our results were
known. 34 problems were independently classified as severe,
and about a third of these were known to the GP (table HI).
This is a much smaller proportion than was known for the
60% of the difficulties overall (table II).
DISCUSSION
TABLE I—HEALTH VISITOR’S ASSESSMENT—ACTIVE PROBLEMS
DETECTED
Classification of problem
Environ
Physical Mental Social mental Carers
lit y tar
No of
problems
No of
individuals
2nd year
No of
problems
No of
individuals
595
33
36
64
‘ 46
226
32
35
54
44
113
15
8
26
26
77
15
8
22
24
None Overall
Case finding in a population of old people always results
in the identification of many problems, some of which were
previously unknown.8-16 The important points in this study
TABLE III—HEALTH VISITOR’S 1st ASSESSMENT—SEVERE
PROBLEMS PREVIOUSLY DETECTED
Type of problem
774
21
264
188
141
253
Knowledge
ofGP
Physical
Known
Not known
9
12
1
2
0
2
1
4
1
2
12(55)
22(65)
Total
severe
21
3
2
5
3
34(100)
Mental
Social
Environ
mental Carers
Total
("o)
THE LANCET, JULY 5, 1986
32
ssW
Animal Experimentation
should be noted that the doctors of the study Pn‘cuce^^
particularly concerned with old people and had a
visiting schedule to those known to have chronic illnesses.
Thus the proportion of problems known to the health visitor
but not to the general practitioners is not likely to telessm
other practices. General practitioners, it seems, need more
specific training about the difficulnes of old age and should
Xrmine the elderly patients overall health and well being as
well as the specific complaint.
We thank Dr H. N. Williams and partners,JSt David’s
Gwent, and fieldworkers: Mrs P- Abbott, Mrs P. Allen, Mrs D Brgnelli Mn
cSle, Miss R. Eaton, Mrs D. Ford, Mrs S. Harhng, M^s S.
Holtermann Mrs J. Hurford, Mrs Y. Lewis, Miss G. Megms, Mrs G.
Ollerenshaw, Mrs A. Pugh, Mrs M. Reess, Mrs K. Scon, Miss S. Ta™P ’
Mrs G. Young; and Mrs P. Rigg and Mrs S. Mowbray for secretarial help.
THE ANIMALS (SCIENTIFIC PROCEDURES)
ACT 1986
Clive Hollands
CammiueefoT the Reform of Animal
10 Queensferry Street, Edinburgh EH2 4PG
THE Cruelty to Animals Act 1876 to remained un
changed and unamended for 110 years despite twc> Royd
Commissions, a Government departmental inquinxand
numerous attempts by Private Members to introduce
^In^VS, after the successful Animal Welfare Year
The Research Team for the Care of Elderly is funded by the Welsh office
andffie Department of Health and Social Security through the Office of the
Chief Scientist.
REFERENCES
,.
OR, Co-
,971:
2. Th^r. Ey— rf -
Br Mal3 1968,
fo'
5. BaXer JH, Wallis JB. Assessment of the elderly in general practice .J R Col
<,
Collet orN™.
“
T.X’T. C^ V.
R Coll Gen Pract 1970; 2(h 27&-S4.
___
I&msggggss.
11. Fairley HF. Unrecognised disease among the elderly in a gen
patients over 75 in general practice. Br Med J 1
>4.
P
in 3^ P^J « «
>97^3>-
“Although psychiatric patients vary enormously, they
share *e dZctensuc of being somewhat emononaUy .sotaed.
The fact that a psychiatrist takes the trouble to get to know than
^Snately
itsetf enormously
or not h<£abb
intimately is
is itself
enormously important,
important,whether
------------XSIe their symptoms. I often think that the tntroductton of
aueviaie ui
----- advantages as well as
]t?seas,y topresaibe^without'necessarily g^tingtoknow
,atient. I think that every psychotherapist ought to, have_one
or two
was right in supposing that psycho-analysis was — - -~
technique for treating the psychotic, the kind of P5?0*1®?1 P*
which aims at understanding rather than cure often makes Ide much
more tolerable for the psychotic patient, simply
there is at least one person in the world who can
Every kind of psychiatric syndrome is made worse y
•
XSX Stokr. Psychotherapy. Bull R Coll P^yduatmt, 1986,
10(6): 142-44.
Tte dto:Xntk.ued to play a vital pm in the P^g^
the Animals (Scientific Procedures) Bill through bo*
Houses of Parliament. In all, over 8*amendments ■were
tabled in the Lords and a further 100 or so durmg the
comminee and report stages in the Commons, out of which
28 were accepted by the Government; of these, 20 ongmated
,
,5. WiS J- D««in« di— » dimoi
16
Campaign, which marked the centai^y °f the A^t was
agreed that a new impetus was needed if the Govemmen
^to take animal welfare seriously. Plans were drawnup
for a novel approach to put animals into pohncsr-a
fXpai£ dirXi at the 1979 generd elecuon with a
slogit “Put it in the manifesto”. For the first rime tn Bnush
partonentary history all the major political parries tncluded
undertakings on animal welfare in their manifestos
The Committee for the Reform of Ammd Experi
mentation (CRAE), established during Anu™’Jne‘1^
Year to seek reform of the law governing ammd
tation under the chairmanship of Lord Houghton of
Sowerby, realised the need to enlist allies if the Govemmen
was to be influenced. Thuswas b°™ tnpkdhan^of die
British Veterinary Association (BVA), CRAE, ™
Fund for the Replacement of Animals in Medical Exper
iments (FRAMEE-a union which had a major ™Pa« 0
Government thinking. A comparison of the first white
paper, Scientific Procedures on Living; Animals Cmnd
8883) 1983, with the supplementary white paper (Cmnd
9521), published in May, 1985, reflects the many changes in
legislation: the restriction of pain; a very substantial
Auction in the number of animals used; the de'^°Pmf1
and use of humane alternative methods of research, an
public accountability.' The Government ProP053}8. “
ronuined in the new UK legislation coupled with a
comprehensive code of practice and a strong
procedures committee can achieve these objectives ana
provide a strong basis for reforms in the way an™als^
bred supplied, and used in scientific procedures. The Act
SXitidsed by some because it does not tan. sp^fic
experiments, but its aim is not to ban selectively but
control all areas where
.
legislation were enacted to aoousn an mu..-.
regulation and thus accountability
will have the
responsibility of making a judgment on the scientific
of Se work he authorises, for which he will be answerable to
Parliament. “In determining whether and on what terms to
,1
(Com H - If.
ROLE OF VOLUNTARY ORGANIZATIONS IN HEALTH AND HEALTH CARE SERVICES
CHAI Study team, Monmunity Health Cell, Bangalore.
15th April,1993.
The Policy Delphi Method of research was utilised as a
component of the larger CHAI Golden Jubilee Evaluation Study.
Forty-nine persons participated as panelists. They came from
diverse backgrounds such as sociology,theology,different branches
of medicine,nursing,community health,communication,law,education,
development etc. The interaction between the panelists and the
facilitators was by mail, using questionnaires and other information
sheets.
In the first round of the method an open question was put to
the panelists regarding the role of voluntary organisations in India,
with respect to health and health care,during the next fifteen years.
Thirty seven panelists (75.5%) responded. A surrerary of the different
ideas that emerged is given below. This particular question was not
taken for the next round which focussed particularly on the role of
CHaI. Therefore, no prioritization or rating of the ideas/issues has
been done. For the purpose of this note similar ideas have been put
together in broad groupings. Most of the roles identified are already
being played to greater or lesser extents by different volags or NG0*8
in the country. Given the broader contextual issues (raised in the
earlier notes) in which health work is situated, it would be important
to reflect as to what could or should be the areas of priority during
the next fifteen years. Arriving at some clarity about this would
help in the planning of work,development of skills,utilisation of time
and other resources etc.
The four broad areas covered,concerning roles of volags are:
1. Priority groups for focus of health related work.
2. Varying types of intervention.
3. Methods of work.
4. Methods for spread of ideas.
I. priority groups for fQCUB pf health related work by volaqs.
/
1,1 Weed to focus on and^support the poor and marginalised!
* Special focus on the rural and tribal poor and on urban poor
living in slums, There is a need to identify neglected groups
among^population,especially those that depend for their livelihood on the fragile eco-system, Strategies of work intervention need to be evolved.
* There is a need f©preferential pption in the provision of
health care for marginalised groups, weaker sections and
neglected areas of the country. These groups are largely
ignored by the elite institutions involved in health care.
There is a need for extension work and increased health care
services in inaccessible rural areas> The market orientation
of health care should be resisted and efforts made to give
good quality care at low prices for the masses.
* Volags could function as spokespersons for the poor and work
to influence government policies in their favour.
* There is also need to ensure that systems of social security
for the poor are effectively implemented.
* While working towards greater Justice for the poor^volags
should also work towards overcoming the difficulties faced by th
poor as a result of the new economic policy. There is scope
for involvement in development work that Will enhance the
capacity of the poor.
1»2
Heed to care for special groups.
Those groups wentioned specially werei
a) Girl children and women - there is need for education and
special health care to counter the anti-girl child bias in our
society. Education and advocacy^ towards empowerment of women is
( 2 )
>
/
required. The health status,infant mortality and population
growth,not to mention the economic status of a community changes
in a positive direction when women are educated and have a sign!—
flcant say in the matter of social decisions etc.
b) Tribal groups.
c) patients suffering from AIDS and leprosy.
II.
Varying types of intervention by volags
2.1
provision of services
seconda
Examples given were as followst
7
and tertja
reventio'
* Mobile clinics in endemic areas for diseases like leprosy.
filaria etc.
♦ Half-way Hospitals closer to the community with facilities for
surgery etc,so that chronic diseases can be tackled at the
contfiiunity level.
♦ Services for the physically and mentally handicapped and the aged.
* Rehabilitation and supportive services.
* Counselling services
<
..
3
* Treatment centres for alcoholics and drug dependants.
* Hospices.
2.2
promotion of preventive and pranotive health services
The following specific areas were highlightedt
* Focus on all preventive and promotive health work*including
mental health.
< Propagation of healthy food habits,diets and exercise for a
better quality of ^fe. .
* Nutritional progrmmes t^-dea^^i^h nutritional deficiency
diseases*
♦ Prevention of communicable diseases.
( £
’
(3)
•
. Mfectlve Implementation of the principle, end component,
of primary heelth core through appropriate .trotegle. for
the attainment of Health for All.
2.3
promotion pf community health and development
* There is a need to work towards community health rather than
institutionalised health care, to focus on general health
rather than on specialised health needs. There is need for
greater stress towards building community based health care.
Rural health centres need to have a community health
orientation.
* Conwunity health care programmes for marginalised communities.with their participation's Iterative. Liberation of
people takes places when communities of people take their
lives into their own hands.
• People should be empowered to do things for themselves by
leaking them realise their self worth and by a building of
self-confidence. Thus people can be helped to be makers
of their own quality of life.
• Health problems should be tackled within the family,the
connrunity and locally as far as possible.
♦ people should be helped to prevent
through their own organisationE.
illness and promote health
* Health programmes should also be developed in the context of
socio-economic development and its impact on health. For
instance,initiating and linking up with programmes that are
indirectly related to health,for example, supply of pure (s»fe)
drinking water,nutrition programwef etc.
♦ There is also need to . provide and to pressurise government to
provide for basic health needs and clean water to all.
( 4 )
Si
promotion of newer dimensions pf health work/health care
The newer dimensions mentioned included the following:
* The vholistic approach to health In which proper priorities
are given to »plritual,moral,inedical,social,economic and
environmental factors. Evolving and promoting the wholistlc
approach by bringing together practitioneis and researchers of
various indigenous health systems.
♦ Use of non-drug therapies.
♦ Promotion of positive health and natural methods of health
care.
* Promotion of self-help health care and home remedies in
rural areas.
I
* People should be enabled to rediscover experience,knowledge,
skills and practices within their communities and give a
scientific basis wherever possible to strengthen what is
!
wholistic and healthy.
* promotion of an enthusiasm among people to build their own
health system in which they are the primary planners and the
real implementators. The authentic result of their health
care will be founded on their innate sense of community,
traditions,simplicity of life style and self-reliance.
* Demystification of health,so that people can use what is
available,accessible and acceptable to them.
* Developing natural resources in the field of medicine.
* Facilitation of consumer movements.
• fV-
( 5 )
v)
fl
Promotion pf a rational/sclentific approach to health care
planning
♦ Need for reassessment,reorientation and rejuvenation of the
considerable voluntary health sector in India. This system
is relatively large in India,but on the whole deteriorating,
inappropriate and wasted.
* To make a constant (continuing) analysis of society and
the heabth system so as to bring about policy changes in
the restructuring of health services.
♦ Provision of cheaper and people’s need oriented health care
by not expanding hospitals Into specialised units.
♦ Developing a system vtiere a few hospitals in each region
could make sophisticated techniques available at reasonable
prices.
♦ To establish a liaison network with appropriate leaders at
different levels to monitor preventive action.
* To establish a network of epidemiological research centres to
forewarn various diseases.
H
♦ Need to develop regionalised health services. To work out a
proper divergent type of referral system wherein specialists
from larger institutions move out to smaller institutions and
provide specialised services.
i
* Need to develop methods for simplification and rapid diagnosis
of common diseases.
♦ The management of health care institutions need to be profess
ionalised using scientific methods.
♦ To work towards legislation that protects andpromotes good
health-for example, prevention of pollution,provision of safe
drinking water.
r
' / 431
( 6 )
( V )
on;-. ■:
II
(
I
* To challenge strategies being followed for "Health for All"
like the G.O.B.I. package (growth monitoring,oral rehydration,
breast feeding and immunisation) and the targetted Universal
Immunisation Programme.
* Influencing policies using scientific evidence and through
building up public opinion.
* To promote/develop innovative,appropriate,feasible and aosteffective programmer, in health care,education of health professionals/personnel, and in development.
I
* To involve peraprofessienals and non-professionals in health
care.
2.6 Besppndjnq to emerging health problems and newer health jegyeg
* Since Government is litely to focus primarily on public health
care, volegs (NGO's) should be the initiatorr cf newer responses/
services for emerging health problems.
• The problem of AIDS,prevention and control,care of aids patients,
including running hospices for them, is one such new problem.
• Environmental health issues are also emerging as being important.
* Health effects of industrial!st/consumerist expansion.
* The present system could be challenged by involvement in issues
like the promotion of essential drugs,campaigning against unne
cessary and harmful drugs and chemicals, challenging practices
of multinational drug companies and hospital corporations,and
the misuse of advertising. There is a need for deroedicalisatlon
of society and demystification of the health profession.
2.7 prorotlon of indigenous and alternative systems of medicine
Io
.
* To help rediscover health systems/health practices that are
indigenous and effective,because they are related to the life
situation,culture and ambience in which people live.
{ 3 ?
( 7 )
Jr
JF
♦
To educate and demonstrate to people the efficacy of herbal
medicine and to instill confidence in them that basic health
can be within their control in normal circumstances.
*
To judiciously use alternative systems of medicine so as to
provide the best possible health care in different areas and
situations.
2.8 To unhold and promote higher Ideals in health care
♦
To keep alive role idealism^humaneness and a holistic approach
in health care. These are the essential •leaven* to counteract
and challenge the proliferation of mechanietic^cor'merclalised
and depersonalised medical/health care.
*
Volags should resist the temptations of competing with private
commercially oriented health institutions which are primarily
concerned with making profits rather than serving the poor.
♦
The voluntary health sector should resist the temptation of going
in for expensive diagnostic and monitoring equipment,which have
been shown to have had no positive impact on the health status
of the Indian people.
♦
To ensure a fair and even generous deal to all personnel working
in volag institutions.
*
To fight for honesty and lack of corruption in public systems
i,
and to ensure the delivery of services.
♦
To be vigilant against malpractices and to mobilise public opinion
against such antisocial activities.
2.9 To develop innovative proqrarnmGF/approaches
*
There is a need to build on the assets of volags.namely their
willingness to serve in difficult areas and ability to innovate,
by converting their limited resources at strategic intervention
points.
By providing services wbejg5retl^^sare none and documenting exper
iences and information that (generated, another important purpose
4( 8 )
4
of policy critique will be made possible. There is a need
for volags to provide critical comments on health policy and
to advocate changes found necessary by the data generated
above.
To develop Innovative methods for the health rupee to go farther.
*
To start innovative Insurance schemes for the poor to increase
their access to existing health services.
To develop motivational strategies to facilitate government
health workers to provide health services.
*
To develop close interactionvith the State so that entire
Blocks/lPrlmay Health Centres/specified areas are handed over
to volags,with the funding. The concept of Primary Health
Care to be used for health work.
To develop viable,affordable and effective models of health care in
in order to enable the poorer section of the population to
afford and have access to health care and participate in its
sustenance.
*
To bring successful innovations to the attention of the health
system for dissemination and adoption.
All resources among NGO’s could be combined to establish
regional centres for production of generic drugstmanufacture
of hospital beds,equipment,bandages etc. Sheltered workshops
and vocational training centres run by NGG’s could be utilised
to provide infrastructure et^ There is a guaranteed market both
for drugs and equipment in NGO/Church hospitals,provided
quality,quantity and price requirements can be met. This
would help in cost reduction,employment creation and production.
i
*
There is a need for reorganisation of medical education to
provide more socially sensitive doctors,with attitudes that will
respect the role and leadership of experts of other disciplines
and give importance to the team concept. There is also a need to
develop relevant models for the education and training of health
workers.
( 9 )
• There is a need to find suitable ways of combining the
excellent ideas of the basic philosophy of VHAI (1978),
ACHAK (1982),CHAI (1983) end CHAI (1986).
III. Methods of interventlon/involvement in health work
There is an overlap between source of the Issues raised below.
There are wide range of suggestions#some of which may appear
contradictory and represent differing approaches.
3.1
Healthactivist
and cornnmnity organisation
Promotion of genuine people’s movements.
e
*
Volags should support activists in the field.
*
Support to people’s movements,organisations and associations
so as to bring pressure on the government to vork and to be
accountable. Organising people and mobilise public opinion
to put pressure on the system for a more just prevision of
services and for a revision of government priorities sc as
to emphasise the health of the poor.
*
Need for awareness building, education and organisation of
people in communities to.critically understand their situation
and to act on it unitedly as the local level.
♦
To enable people to develop and express their own ideas
regarding health and healthy communities, To enable people
to organise themselves to provide their own health services
and to develop life styles within a self-reliant mode, that is.
to take health back from the •technocrats*.
Campaigning towards bringing in legislation to ensure account
ability and transparency in the functioning of government (and
its health system).
*
Conscientisinc and organising consumers against unhealthy
practices. Bringing about a change in societal attitudes re
garding consujmerism,profiteering and cultural alienation.
( 10 )
Working towards community participation in health care.
Mobilisation of people as volunteers in the neighbourhood
to take care of the health aspects of that area.
*
11) Betworkinq
To develop working relationships and an effective network with
activists and other groups involved in issue raising/lobbying/
advocacy work in the field of health,education,agriculture,tech
nology and science.
This is for mutual support,encouragement
and solidarity.
r
■ 11) Coordination
Coordination of programmes for health care (between volags) to
avoid duplication and to help bring about better utilisation of
services.
*
intersectoral and intrasectorial coordination of services.
lv) Collaboration
*
To work as partners with each other and with government towards
achievement of Health for All.
*
To colleborate with government in improving the level of
efficiency and quality of services offered at government hospi
tals and health centres.
v) Liaison
To be a link and bridge the gap between the community/public
and the health autorities of the government sector to improve
understanding,explain constraints etc. This liaison would help
people to get access to 'government facilities' using a construc
tive, non-threatening approach. Thus people will not have to
suffer when a volag/toGO withdraws.
( 11 )
vl) Research and I valuation
♦
To promote research,documentation and evaluation by volags.
♦
To undertake research to identify emerging health issues and to
develop new solutions.
<
♦
To develop appropriate technology through a process of study
and research to deal with various health problems.
♦
To promote study/analysis of social and health problems,parti
cularly the social aspects of health.
♦
To conduct operational research and undertake studies to pinpoint
the lacunae in our system.
♦
To help in generation of national data about health changes
occuring et the community level.
♦
To study alternative systems of medicines and their effects. To
promote systems research in the efficacy of integrated medicine.
♦
Research and evaluation of ongoing projects* Voluntary hospitals
in general are required tc do a lot of self-analysis and re
examination of their role. Many of them have outlived their
objectives and are not clear about their philosophy,objectives
and goals in the context of current changes and developments.
There is a need to re-examine their service effectiveness,cost
effectiveness and quality of service.
I
IV,Methods for spread of ideas
4.1 Advocacy/Lobbying
♦ Advocacy can be ar two levels,namely>
a) by networking at the macro-level for health and
social justice,
b) by education,organ!sation and development — to help
communities get better health care ano services from
the government.
This is cost effective and has widespread effect.
( 12 )
1
Volags should lobby as an active group to influence the
social,economic and political policies of the government,
which may have direct and indirect effects on health and
*
health care services.
Among several areas it was suggested that advocacy for respec
ting human life needs to be taken up.
*
A strong lobby needs to be built to regulate the standard
©f operation of health services.
*
Need for a lobby group to influence governmental and voluntary
organisations to maintain the capacity and quality o« the
medical profession.
t
There is a need for information diffusion with greater media
♦
coverage to highlight health and social problems.
4.2
Creating critical awarenees/education
.
Voluntary agencies need to create a deep and critical aware
ness among people at the grass-root level about th. real economlc,political and social situation prevalent In the
country. Once awareness has been createu people must be helped
to organise themselves to demand their rights with regaroe to
health, housing and education. Because In .»y system, changes
,111 never come through people at the top or even at the .Mole,
but at the bottom.
.
WU4S could fadlltau I'. e ir.terlorisetlcn of the «1’«
eoucmou.kr.o-leage tn’ learning fcr liberation Iron exploitation
and deprivation.
♦
regarding the rights of people, witnout
Need for education
the community and which helps with preserving
causing harm to
the good value based traditions that exist®
Need for awareness building among the public about the
encies and exploitative nature of the health system prevailing
in our country.
X 13 )
Since, according to WHO, 80 per cent of illnesses in
developing countries are preventable, the voluntary health
sector should concentrate on health education at the village
level.
knowledge and expertise and the process
Dissemination of health
of learning to the deprived sections of society through the
*
■edia.
f
*
Heed for an emphasis on the promotion of health and the ways
and means of achieving it, through education.
*
Meed to focus on the
*
Physical and mental health education with focus on teaching
of traditional health care methods like yoga.meditation etc.
social aspects of health, in education.
Teaching of self-help, health care methods.
*
Awareness building regarding sanitation.
♦
Education to prevent AIDS ano addictions.
*
Education to maintain a correct and healthy attitude to the
medical profession#both among the- public andamong medical people.
*
*
Increasing the use of mess media for health education.
*
Introducing an effective machinery
i
i
for health education.
Literacy along with health care programmes.
with health components.
Adult education in rure? and trihal areas
♦
4.3
Public education for information sharing end action.
TrainJ ng
*
Reed lor training at the grass root level and in the informal
sector.
*
rurfcl women wit/h he si th
To evolve training progrs^-ef. to
and jnedicaJ. expertist, sc thet they cen dleseminete health
information aronc the people.
( 14 )
■\
i
(
GOVERNMENT OF KARNATAKA
BASIC MINIMUM SERVICES
DEPARTMENT OF HEALTH AND FAMILY WELFARE SERVICES
BANGALORE
BASIC MINIMUM SERVICES
INTRODUCTION
1.1
A basic health care service is understood to be a new-work of co-ordinated
peripheral and intermediate health units capable of peforming effectively a selected
group of functions essential to the health of an area and assuring the availability of
competent professional and auxiliary personnel to perform these functions.
1.2
The national norm for a sub-centre vary between 3000-5000 population
depending upon terrain and location. Similarly, there should be one Primary Health
Centre for every 30,000 rural population in the plains and one Primary Health Centre
for every 20,000 population in hilly, tribal and backward areas for more effective
coverage. There should also be one Community Health Centre, for every four PHCs,
with 30 beds and specialists in Surgery, Medicine, Gynecology, Paediatrics,with X-Ray
and Laboratory facilities. The District-wise number of Primary Health Centres and
Community Health Centres in the State, is given in Annexure-I.
4.3
According to Section 184 of the Karnataka Panchayat Act, 1993, read with
Schedule 3 of the Act, management of the hospitals and dispensaries, excluding the
hospitals and dispensaries under the management of the Government or any other
Local
Authority,
implementation
of
Maternal
and
Child
Health
Programme,
implementation of Family Welfare Programmes and implementation of Immunisation
and Vaccination Programme are the functions of the Zilla Panchayats.
1.4.
Establishment of new PHCs and CHCs are proposed by the Zilla Panchayats
and sanctioned by the State Government. Sanctions are normally accorded on the
last day of the financial year and many a times the PHCs sanctioned are different from
those proposed by the Zilla Panchayats. AJarge number of PHCs, which have been
sanctioned in the recent past, are yet to become functional. Buildings are yet to be
constructed and the staff, as per the norms, is yet to be sanctioned to these newly
sanctioned P.H.Cs.
1.5.
Since the Sub-centres and PHCs in the State are much more than as per the
national norms, the emphasis should be on making the already sanctioned Sub-
2
centres and PHCs functional by construction of buildings, sanction of staff, providing
equipment, etc.
2. PLANNING COMMISSION ON BASIC MINIMUM SERVICES.
2.1.
During discussions with the Planning Commission, it has been pointed out that
taking cognisance of the widening disparities among the States in the availability of
Basic Minimum Services(BMS),the Conference of Chief Ministers in July, 1996,
recommended that Additional Central Assistance(ACA) may be provided to the States
for correcting the existing gaps in the provision of seven Basic Minimum Services; that
of these, access to primary health care, safe drinking water and primary education
were given higher priority with the mandate that universal access to these services is
to be achieved by 2000 A.D., that unlike the Minimum Needs Programme, which
provides funds only for rural primary health care, BMS includes primary health care in
urban and rural areas; that in order to ensure that adequate investments are made for
BMS sectors, minimum adequate provision(MAP) was calculated on the basis of
Actual Expenditure for 1995-96 + ACA + 15 per cent of ACA as State’s share, that the
a
State.Govemment must also ensure their share of 15 per cent for BMS; that failure to
allocate and utilise MAP requirement would result in curtailment of Central Assistance
in the following year; that during the Ninth Plan funds will be ear-marked for urban and
rural primary health care under the name BMS(instead of MNP); that this ear-marked
amount will include BMS allocation from state budget and that since primary health
care is one of the priority areas identified under BMS the State Health Department may
obtain upto 20 per cent of the ACA for BMS for bridging infrastructural gaps in primary
health care.
2.2.
The Planning Commission has, among other things, emphasised the following:
a) While computing the requirements for primary health care infrastructure for the
growing population, the fact that the population increase has occurred
in and around the already established centres have to be kept in mind. Since
the already established physical infrastructure cannot be shifted, and it will be
difficult to add additional centres to serve the population in geographically
convenient locations, it would be more feasible to increase the number of
functionaries required to cater to the population's need rather than increase the
number of centres.
b) During the Ninth Plan period the States shall restructure the existing subdistrict/taluk hospitals and block level PHCs into functioning CHCs to the extent
possible.
c) Existing rural hospitals and dispensaries have to be restructured to PHC/Sub-
centre.
d) The poorly peforming districts should be identified and essential funds provided
to meet their requirements so that the existing
gap in the health and
demographic indices among these districts could be minimised.
e ) A flexible approach to the recruitment of staff, if necessary on contract basis,
will be adopted to ensure that the programmes do not suffer due to lack of key
personnel.
f)
There is a lack of critical manpower in primary health care institutions. The
number of sanctioned posts of Male Multipurpose Workers is only half the
number required. This has been cited as one of the major factors responsible
for the suboptimal performance in Malaria and T.B.Control programmes. It is
essential that necessary administrative steps are taken to fill the gap in Male
Multipurpose Workers.
g) -A substantial proportion of specialist^ posts even in functioning CHCs are
j/acant Hence these CHCs are unable to function as First Referral Units. In
view of serious implications of this lacuna in the establishment of referral
system, as well as effective provision of health.MCH/ F.P.Care, there is urgent
need to rectify this.
h) At the moment there is no post of Anaesthetist in the CHCs.
Anaesthetists are vital
Services of
because without an anaesthetist emergency/routine
surgery in CHCs will not be possible. Attempts may be made to provide this
critical manpower.
i)
Services in primary health care facilities are also affected due to lack of
maintenance of equipment/vehicle and inadequate supply of drugs.
3. CONSTRUCTION OF BUILDINGS FOR SCs, PHCs and CHCs:
District-wise requirement of funds, for providing buildings to these centres, is
shown in Annexure-ll.
4.PR0VIDING STAFF TO PHCs AND CHCs AS PER NORMS:
4.1
The PHCs sanctioned since 1989-90 and the CHCs have not been provided with
full complement of staff. To make these centres fully functional, the following staff is
required to be sanctioned.
For PHCs
1.
2.
3.
4.
5.
6.
7.
8.
4.2.
Block Health Educator.
~
Senior Health Assistant(Male)
Senior Health Assistant(Female)
Staff Nurse
,Junior Health Assistant(Female)
First Division Assistant
Second Division Assistant
Group 'D
For CHCs
1. Paediatrician
2. Gynecologist
3. Surgeon
4. Dental Surgeon
5. Office Superintendent
6. X-Ray Technician
7. Staff Nurse
8. Pharmacist
9. Typist-cum-Clerk
10. Second Division Assistant
11. X-Ray Attender
12. Lab. Attender
13. Helper for every 3 beds
14. Cook15. Dhobi
In addition, the post of Anesthetist is also required to be sanctioned to the
CHCs. The recurring expenditure on the staff to be sanctioned, district-wise, is
shown in Annexure-lll.
5.
MALE MULTIPURPOSE WORKERS:
As against the requirement of 8143 male multipurpose workers, there are only
6352 sanctioned posts. Hence, 1791 posts of male multipurpose workers will have to
be sanctioned.
The recurring cost, district-wise, for these posts are shown in
Annexure-IV.
6.
SUPPLY AND MAINTENANCE OF EQUIPMENT, FURNITURE, DRUGS, Etc.
Funds for supply and maintenance of equipment, furniture, drugs, etc., are now
available, to some extent, under the Externally Aided Projects like I.P.P.-IX, KHSDP,
5
RCH, etc. However, once these projects are over, adequate funds, for this
purpose,will have to be provided in the budget.
7.
TOTAL ESTIMATED REQUIREMENT OF FUNDS FOR BMS (RURAL).
As of now, the total estimated
requirement of funds for providing the basic
minimum services, in rural areas, is Rs.389,52 crores (including recurring costs of
Rs.85.5J crores-). This amount may be provided over a period of 2-3 years. Since, as
already pointed out earlier, primary health care services are basically in the Zilla
Panchayat sector, the funds required will have to be provided to the Zilla Panchayats.
•
ANNEXURE-I
• Si.No.
Name of the District
No. of existing
Sub Centre
No. of Existing PHCs
No. of existing CHCs
1
2
3
4
5
140
286
31
73
57
70
82
97
55
135
3
11
12
7
13
10
9
15
8
10
3
6
11
02
1
2
3
4
5
6
7
8
9
10
11
12
13 »•
14
15
16
17
10
19
20
21
22
23
24
25
26
27
Bangalore Urban
Bangalore Rural
Chitradurgan
Davangere j
Kolar
Tumkur
Shimoga .
Bel gaum__
Bijapur 1
BagalkoteJ
Dharwacfj
Gadag
r
Haveri J
Uttara Kannada
Gulbarga
Bellary
Bidar
458
375
418
380
598
456
I
596
316
512,
264
231
i.
28
29
50
61
’105]
Tssr-
Koppal j
Mysore
j
Chamarajnagarj
Kodagu
Mandya
Hassan
Chickmagalur
Dakshina Kannada
Udupi
708
T41
47
43
96
52
29
71
81
51
64
63
TOTAL
8143
1676
Ralchur]
,
690
163
376
463
335
/6
5
15
4
7
9
05
8
7
6
249
c-cVa'-''- -j
^cr:<;^do.560(J09
ANNEXURE-II
Rs. In lakhs
Si
NO
Name of the
District
No.of Amount
No.of PHC
Sub Centre required Buildings
Buildings
to be con
to be
•
structed
constructed
2
1
3
1 Bangalore U
2 Bangalore R
3 Chitradurga
4 Davangere
5 Kolar
6 Tumkur
7 Shimoga
8 Belgaum
9 Bijapur
10 Bagalkote
88
4
396.00
••
74
190
105
160
105
63
333.00
855.00
472.50
720.00
472.50
283.50
50
225.50
12 Gadag
90
13 Haveri
98
14 Uttara Kannada
223
15 Gulbarga
265
16 Bellary
107
17 Bidar
103
18 Raichur
170
19 Koppal
102
20 Mysore
203
21 Ch am ar a J anagar
161
22 Kodagu
66
23 Mandya
170
24 Hassan
259
25 Chikmagalur
220
26 Dakshinna Kannada
27 Udupi
289
405.00
441.00
1003.50
1192.50
481.50
463.50
765.00
459.00
913.00
724.50
297.00
765.00
1165.00
990.00
11 Dharwad
TOTAL
3453
1300.50
15538^
5
Amount
required
No.of CHC
Buildings
to be con
structed
Amount
required
Total-amount
required (Total cf
Col.No.(4)+(6)+(8)
6
7
8
9
4
4
3
300.00
300.00
225.00
5
3
3
1
4
1
1
4
4
3
2
1
5
2
3
3
4
5
5
2
3
1
375.00
225.00
225.00
75.00
300.00
75*.00
75.00
300.00
300.00
225.00
150.00
75.00
375.00
150.00
225.00
225.00
300.00
375.00
375.00
150.00
225.00
75.00
592.50
1302.00
843.00
2236.50
949.50
597.00
1464.00
2134.50
1536.00
261.00
1789.50
5700*00
30400.§0
31
25
30
15
28
26
31
16
10
4
10
17
10
59
13
3
9
13
61
558.00
450. <p0,
540.00
270.00
504.00
468.00
558.00
288.00
130.00
72.00'
180.00
306.00
180.00
1062.00
234.00
54.00
162.00
234.00
1098.00
18
33
23
324.00
594.00
396.00
36.00
414.00
■509
9162*00
22
2
1254.00
993.00
936.00
603.00
1734.00
1165.50
1003.00
835.50
763.50
372.00
660.00
1047.00
1483.50
2479.50
865.50
? V.
n
T"
ANNEXURE-III
si
NO
Name of the
District
1
2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Bangalore U
Bangalore R
Chitradurga
Davangere
Kolar
Tumkur
Shimoga
Belgaum
Bijapur
Bagalkote
Dharwad
GadacJ
Haver!
Uttara Kannada
Gulbarga
16
17
18
19
20
21
22
23
24
25
26
27
Amount required for Amount required for
: the staff to be san the staff to be san
ctioned to PHCs as
ctioned to CHCs as
per norms
. per norms
3
Amount required for
the post of Anaesth
etist to be sanctio
ned to CHCs.
4
Bid ar
Raichur
Koppal
Mysore
Chamarajanagar
Kodagu
Mandya
Hassan
Chickmagalur
Dakshina Kannada
Udupi
62.95
255.65
206.95
243.52
229.17
320.72
207.16
501.58
241.18
152*22
98.28
99.21
147.92
151.09
346.99
183.59
107.96
164.93
151.87
351.15
141.82
76.40
240.74
298.14
156.84
176.52
179.91
97.10 ‘
58.26 ‘
58.26 ’
19.42
76.68
19.42
19.42
76.68
76.68
58.26
38.84
19.42
97.10
38.84
58.26
58.26
76.68
97.10
97.10
38.84
58.26 ■
19.42
TOTAL
5494.46
1469O92«
Dellary
Rs."'in lakhs
76.68
76.68
58.26
Total amount rem—=<i
per annum as recumnc
expenditure.
5
' 6
2.^0
8.70
15.95
11.60
11.60
7.25
15.95
10. 15
10.15
4.35
8.70
15.95
13.05
23.20
11.60
7.25
7.25 ’
13.05
18.85
4.35
4.35
10.15
17.40
5.80
8.70
5.80
65.£5
341.03
299.58
307.58
240.77
429.42
272.67
575.79
270.75
239.05
122.05
127.33
240.55
240.82
42g.45
234.03
134.63
269.28
203.76
428.26
204.43
157.43
347.99
412.64
201.48
243.48
205.13
279.85
7244.23
.
5.80
•r
ANNEXURE-IV
Si
No
J_
‘DISTRICT
Total No. of Male MPWs
required as per norms
_______________ 3_____________
Existing No. of
sanctioned post
________ 4_____
Balance No. of posts
to be sanctioned
_________ 5_________
_______ Rs. in lakhs
"
Recurring expenditure;per
annum for^the post in Co11no.5
__________ '•
6
'
___
BANGALORE DIVISION
i.
1
B angalore
140
130
10
7.30
2
Baogalore Rural
286
3
132
5\.<
25„
4 128
37.23
Chitradurga
Dayangere
Kolar
6
Shjmoga
300
235
107
190
282
249
7
Tumkur
410
390
4
5
u
131 .
20
10.25
93.44
67.09
95.63
14.60
121
416
40
182 :
29.20
132.86
295
174
• 284
11
49
0.CB
125
326
375
TOTAL
‘
B ELGA UN DIVISION
8
9
10
ii
12
B agalkot
Belgaum
B ijapur
Pharwad
4
4 «•
161
(
590
35.77
126
91
35 •
25.55
13
Gadag
Haver!
296
21T
62.05
14
Uttara Kannada
316
85
36A
£• ?
r.
280 '
26.28
TOTAL
Pro
A
I
_ i-;-f f
- ef-{.
ttj
. .
^7-’; *2-
■f- 1 'i«q
..
'
•
s 1’’7
:NP"'»
_
J - •n •
J’:1
• •'-
:
.i
•i'
: c .
District ;
t;
no?.
T
. ‘JOf.
l_L *
6
OM.V
GULBrtRGA DIVISION
is
B efl'ary
16
Bidar
. Guibarga
17
•
18
19
. \ Cl
:•; »
r: i
231
512
- < L
’
•
Koppalj
172
Ralchur
I'/..’
206 x ‘
/.
4
MYSORE DIVISION.
ChamaraJanagara
21
Chickmagalur
22
Dakshina Kannada
' • *
23
HassanS
24
Kodagud
Mandya2.
Mysore
Udupl
25
26
27
456
163 j
376 .
488
252
TOTAI- -ST7VTE TOTZiL
J
8143
23
i
49
. 452
t f£
i.‘ 163
’ 165
LT-?
i
60
9
41
‘ X«.
I
... 16.79 J L
35.77 i | :.
43.80
f c.‘ •
i
6.57
’r r
■ i
d
r
29.93
I
i
I
I
I
I
71
61^'.
305
30
I { •>.?
323
133
332
i’-' r i
pri
131
I
I
II
I
rr. £
94
•• ('£ -
320
56
1
330
158
!
187
6352
69 '
. .:e
65
1791
I
I
i
I
I
. I
■I
VI
46<3 :
•
I
-t
202
335 j
c^r.
182
<• • £
TOTAL
20
241
8
51.83
21.90
01
97.09
95.63
.I
50.37-j
a
40.88 i
115.34 j
47.45
.1307.43
VtImv---- rAs----
’
i .
’
I
I
I
I
I
c'
h''
i
Christian Medical Commission Meeting
World Council of Churches
150 route de Ferney
1211 Geneva 20, Switzerland
CmCffl/68/14
PLANNING FOR HEALTH CARE
(A summary of the discussions which led to a consensus on the
Commission’s understanding of its task).
While we are justifiably entitled to pride in reviewing the legacy
of Christian medical work, we realize that some of the earlier
initiatives are no longer open to us and that we must search for
a new relevance today. Part of what was distinctive in Christian
medical programmes was its pioneering nature - in offering medical
care to those who otherwise would be destitute. However, today,
governments and other secular agencies are increasingly offering
such services, and we must discover how our programmes can be
coordinated with theirs, This is not to say that the pioneering
aspect of our services is over, There are whole new dimensions of
pioneering possibilities which are still open to us. Yet in the
discovery of them, we must always be aware that relevance is always
relative. What is relevant today may be quite irrelevant in the
days to come, and so we must always be open to renewal as we search
for the appropriate ways in which the church can bring healing and
wholeness to man.
A review of the problems which face individual institutions makes it
abundantly clear that we lack adequate mechanisms for planning, The
majority of these institutions operate in isolation from others,
and their priorities and programmes are determined within the narrow
context of their institutional walls. Thus, appeals for financial
assistance go to the agencies with which they are historically
related or to donor agencies. Yet such projects may have little
relevance within a regional or national assessment of priorities.
Because we lack mechanisms for planning, our present goals for the
delivery of health services are largely undefined and they may be
inappropriate in terms of community health needs.
The most important new dimension in the field of health care today
is the element of planning, and most national governments are now
engaged in it. Such planning seeks to define overall objectives
and to identify the resources which are, or may be, available to
meet them. It is now incumbent upon the churches to engage in such
planning themselves, if they would exercise stewardship with their
resources. Planning is necessary at all levels - national,
institutional, and even at the level of dispensaries - and there
must be a correlation at all these levels. Stewardship is required,
not only to achieve the optimum health care within our resources but,
equally, to see that the results are economically viable in the
local context. We must always beware lest we advocate a system for
2
the delivery of health care which is beyond the reach of patients
who are asked to pay for it. Modern technology is making hospital
care more and more expensive. Yet most Christian hospitals seek to
demonstrate the highest professional level of care believing this
to be an effective part of their witness. It is ironic that in
doing so they often price their services beyond the reach of the
very poor who most need them. In such a situation, these institutions
may have an aura of affluence and an image of indifference.
Ule were asked to consider the disturbing question, "Can uie exclude
from our mortality and morbidity statistics those we could not afford
to care for?" Thus it may be appropriate for the church to develop
experimental programmes directed toward minimal cost medical care,
facing realistically the issue of cutting costs without too much
increase in the risks.
One theme, which recurred again and again, was that the focus of care
must change from the individual to the community which includes all
individuals. This was pne area where theologians and health planners
found common ground. While the church had emphasized personal
(individual) salvation, it was now coming to recognize that the
uniqueness of the individual most frequently lay in his relation
ships in community. So there was a need to recapture the Hebraic
concept of corporate salvation and the Pauline version of it as
the New Community in Christ. Likewise, health planners were now
aware of the deficiencies of a hospital-centred, disease-oriented
system which focused on the individual who came to the hospital, but
tended to neglect those beyond its walls who might be in greater
need. Often we were reminded of the TObingen Consultation which saw
the ministry of healing vested in the congregation which moved out
to engage human need beyond itself. And in seeking this role, our
Chairman reminded us of the great danger that in seeking to do things
with people our patience often runs thin, and so we tend to do
things for people which easily gives way to doing things to people.
As an element in the planning process, we were reminded that modern
biomedical technology, which requires expensive hospitals and
equipment for its implementation, can have only a limited impact on
the serious health problems that are before us. The vast efforts
of personnel, money, buildings and equipment, which are required in
the modern hospital, may have only a minimum effect on the total
health need. The child with malnutrition and diarrhoea awakens in
the night with ear-ache and is brought to the hospital; he receives
penicillin and eardrops and returns home again. The suffering of
the moment is relieved, and that is very important, but the effect
on the child’s life and probable early death is not minimized by
this contact with modern biomedical technology. An auxiliary nurse
visits a home, and there is contact between mother and nurse, but
nothing happens. This is the interface between what we know about
disease and what we have to learn about health care. But the fact
that we have limited effectiveness in this area does not seem to
deter us from continuing with this enormous and at times unavailing
effort of building ever more and ever larger institutions.
- 3 Considerable discussion centred on the suggestion that our planning
should involve a fearless appraisal of what we can and cannot do.
This was coupled with the urgent need to work with governments in
the development of priorities and programmes. This echoed the now
familiar concept that we should work within ’’the world’s agenda”.
There is a sense in which these health problems are the world's
agenda, and the question is to what extent or in what way does the
church accept them without question. Dr Taylor made an earnest plea
that we must not simply react to this agenda, but that we should
lead in its development of priorities and methods of meeting them.
The discussion following the presentation of case studies, which
represented problems of church-related medical programmes, made the
delineation of roadblocks to planning especially clear. There is
an urgent need to evaluate the best use of resources. How can donor
agencies become a part of the planning process, so that their gifts
provide the optimum of health care and giving does not destroy the
integrity of those national churches which ultimately become the
owners of these prestigious institutions? It was recognized that
one of the complications of our present situation is that we have,
on the one hand, a system of relationships with agencies and churches
who have resources and, on the other, with churches and agencies
that have needs. If change is to come, it must be at all levels of
these relationships - the institutions requesting aid, the donor
agencies which are in a position to give it, and the national
churches which have ultimate responsibility for the institutions.
And to make the interaction of these relationships all the more
difficult, we have the complicated problems of ecclesiastical
identity which always appear to be so important, even though they
have never been an instrument of healing.
We were reminded of the frequently inappropriate adaptation of
Western styles of hospital-centred care and the educational systems
that have been developed to support them and which are often
impossible to adapt to local situations or cultural factors. In
such cases, while the church must retain a degree of freedom to
experiment, if it has adequately assessed the needs, it is also
imperative that it engage in consultation with governments and not
simply develop its own programmes for the sole purpose of keeping
its institutions running at the cost of an impossible social burden
on those whom it trains.
For example, in our church-sponsored educational programmes, there
must be adequate thought given to the maintaining of government
standards, as well as the need to plan that the person trained will
be always employable - i.e, not beyond the capacity of the economy
to absorb at any particular time, nor frustrated by being trained
at a level that permits no further advancement.
We must seriously consider whether the Commission could make a
significant contribution, not simply by finding ways to adhere to
standards that are often too inflexible and not completely relevant
to the national situation, but by exploring the wide-open field of
community health nursing, a field in which everyone is eagerly
*
4
seeking help*
In reacting to the presentation of these problems, Drs Chandy and
Ademola reminded us that, while we may be able to reach objectives
within an international framework of accepted values, we must never
forgot that the solutions must always be developed within a local
context* These solutions have to reckon with local economic factors,
local personalities, and local colonial heritage. The per capita
expenditure on health within different developing countries varies
considerably, and this forces us to reckon within different contexts
in which solutions must be found, but also warns us that requests
for answers cannot be quick answers if they are to be good answers*
While much of the previous discussion appeared to indicate a down
grading of institutional, hospital-centred care, we must never for
get that the hospital has a vital role within a comprehensive com
munity-oriented health programme. People in communities have a
very wide range of health needs* Some of these health needs are
best met in the home situation - things that have to do with
situations that happen in the home, relationships between people, the
care of children, living patterns, relationships to environment.
But there are other things that cannot be taken care of in the home
- simple things perhaps, such as a boil, a red eye, attacks of
malaria, a cut, and perhaps these can best be taken care of in a
simple centre by a person with simple training. But there are other
things that neither of these situations take care of, such as a
woman in obstructed labour. There is only one place for her and
that is in the hospital where someone is competent to take care of
her need* In order to give comprehensive medical care, we must
carefully assess all the needs of all the people and recognize that
these can best be met in various institutions, each in careful
coordination one with the other* It is when they are separated
that things begin to fall apart; when the hospital in isolation only
meets part of the problem and complicates the issue by sometimes
meeting problems that could easily be taken care of elsewhere, in a
less expensive and less sophisticated establishment.
Having reviewed some of the major problems facing Christian medical
programmes today in all their complex relationships, we recognize
that but a few of them can be responsive to individual solutions,
while behind the majority lies a fundamental need for change. From
these discussions, there emerged a consensus that the direction for
change points to the adoption of a central concept in health care
which recognizes the total needs of man in the community. This
resulted in the document. "The Commission’s Current Understanding
of Its Task", available from the Geneva CITIC office.
Leading Health Indicators for Healthy People 2010: Final Report
Page 1 of 46
Co MH | L
Leading Health Indicators
for Healthy People 2010
Final Report
Carole A. Chrvala and Roger J. Bulger, Editors
Committee on Leading Health Indicators for Healthy People 2010
Division of Health Promotion and Disease Prevention
INSTITUTE OF MEDICINE
X
IOM Logo
NATIONAL ACADEMY PRESS
Washington, D.C. 1999
Notice | Committee | Acknowledgments | Contents
NATIONAL ACADEMY PRESS • 2101 Constitution Avenue, N.W. • Washington, DC 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are
drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of
the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in
the examination of policy matters pertaining to the health of the public. In this, the Institute acts under the Academy's 1863 congressional charter of
responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr.
Kenneth I. Shine is president of the Institute of Medicine.
Support for this study was provided by the Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services,
(contract no. 282-98-0018). The views presented are those of the Institute of Medicine Committee on Leading Health Indicators for Healthy People
2010 and are not necessarily those of the funding organization.
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Copyright 1999 by the Institute of Medicine. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history.
The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Musseen in
Berlin.
COMMITTEE ON LEADING HEALTH INDICATORS FOR HEALTHY PEOPLE 2010
Roger Bulger, MD (Chair), Association of Academic Health Centers, Washington, DC
Susan Allan, MD, JD, MPH. Department of Human Services, Public Health Services, Arlington, VA
Neal Halton, MD, MPH, School of Medicine, and School of Public Health. University of California, Los Angeles
Barbara S. Hulka, MD, MPH, Department of Epidemiology. University of North Carolina, Chapel Hill
Thomas J. Kean, MPH, Strategic Health Concepts, Inc., Englewood, CO
Scott C. Ratzan, MD, MPA, MA. Academy for Educational Development, Washington, DC
Stephen C. Schoenbaum, MD, MPH. Harvard Pilgrim Health Care oi'New England, Providence, RI
Mark Smith, MD, MBA. California Healthcare Foundation, Oakland
Shoshanna Sofaer, DrPH. Baruch College, New York, NY
Robert B. Wallace, MD, Department of Preventive Medicine, University of Iowa, Iowa City
Staff
Carole A. Chrvala, Study Director
Kelly Norsingle. Project Assistant
Kathleen R. Stratton, Director, Division of Health Promotion and Disease Prevention
Donna D. Duncan, Division Assistant
Acknowledgments
Healthy People has been a product of the efforts of many agencies and individuals during the course of the past two decades. The
committee expresses its appreciation to the presenters at the June 1998 public session for providing an excellent overview of the
leading health indicators as they relate to Healthy People 2010. The presenters addressed many of the issues under consideration by
the committee, and the committee appreciates the participants' insights. The presenters were: Edward Sondik, National Center for
Health Statistics; Mike Stoto, Department of Epidemiology, George Washington University; Ronald Bialek, Public Health Foundation;
Thomas Milne, National Association of City and County Health Officials; Laverne Snow; Association for State and Territorial Health
Officers; and Olivia Carter-Pokras, Office of Minority Health. The committee also thanks Michael McGinnis for providing the
committee with his summary of leading health indicators for Healthy People 2010.
This report has been reviewed by individuals chosen for their diverse perspectives and technical expertise, in accordance with
procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to
provide candid and critical comments that will assist the authors and the Institute of Medicine in making the published report as sound
as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge.
The content of the review comments and draft manuscripts remain confidential to protect the integrity of the deliberative process. The
committee thanks the following individuals for their participation in the review of this report: Ross Brownson, St. Louis University;
Ezra Davidson, Charles R. Drew University of Medicine and Science; Paul Frame, Tri-County Family Medicine; Randolph Gordon,
Bon Secours Richmond Health Systems; Maureen Henderson, University of Washington; LaDene Larsen, Utah Public Health
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Association; Anthony Robbins. Tufts University; Susan Scrimshaw, University of Illinois at Chicago; and Hugh Tilson, Glaxo
Wellcome Company.
Although the individuals listed above have provided many constructive comments and suggestions, responsibility for the final content
of this report rests solely with the authoring committee and the Institute of Medicine.
Contents
exk;(jtive: su.mmary
Charge to the Committee
C’vcrview ofTndicatot. Set Peveloprn^
L^escription of Propose3j.Indicp.l30i’. Sets
Linkage of.Indicator.Sets.to
CrosscigrLng.JiJakLlssues
Dissemination Strategies
Conclusions and.Recotnniendaiioos
L..BA€KGR(X)NDANIlSKfN[rK^N(:E
Healthy People- I he First Decade
Leading Health Indicators
2 AHtOA€HTODEW£OPMEOT^
Charge to.Committee
Review of Relevant Literature
P.y.Y^9pnient.of .Criteria.to .Guide^..Selecdon.oESp.ecihc.L-cadi.n
R^gionaLMeetings
Se.lectipn..ofCon^
lntenm.Rcpo.rls
Public Hearing
ScLection.oiX'andidatc
3....PROP()SmiLEAMNG HEAIJ?HJNp]rAT(®SE:rS
Health Determinants and Health Outcomes Indicator Set
Life.Co.urse .Deterininants Set
The PreventLQn:iQricnted.Scf
General Discussion of Issues Relevant to the Proposed Indicator Sets
4.J:INKAGEWrrH^^;^LEEP^2^Z(?
5 CROSS-CUTTING DATA ISSUES FOR LEADING HEAL-TH INDICATORS
Data Sources fpr.Proposed Leading.Heaiyi.Ln
General ..Data Issues .for.I.Tcu^osed Leadip.g.He
6 CONCLUSIONS AND RECOMMENDATIONS
Commitment ofAdequate..Resouraes.and Effort for Disseminatfon^
Heakh_Pisparities
Poveity as a Leading Health Indicator
General.LMajssues and Analvsis aLMuLtiple Jurisdiction Ley
REFERENCES
Executive Summary
Since its inception in 1979, Healthy People has been a significant and innovative health initiative to guide the efforts of this nation to
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(1) address disparities in health status and health outcomes between diverse population groups and (2) improve the overall health of
the nation. Healthy People identifies opportunities at the national, state, local, and community levels to remediate the most significant
and tractable issues affecting the health of all people residing in the United States. With its goal statements, focus areas, and
objectives, Healthy People suggests ways to improve the health of the nation's population while using the knowledge and skills of
national, state, and local government agencies, individual and group participants in communities, members of health care delivery
systems, voluntary groups, and public- and private-sector organizations and agencies.
Healthy People 2010 is the third generation of this health initiative that is intended to address the health problems of this nation as it
enters the next millennium. Efforts to develop Healthy People for the decade from the years 2000 to 2010 have been under way since
September 1996. Although the identification of overarching goals, enabling goals, focus areas, and related objectives for the full
Healthy People 2010 guidance document has dominated these efforts, much attention has also been given to the development of a
small set of leading health indicators.
Similar to the five key measures in the first decade of Healthy People and the 47 sentinel indicators established for Healthy People
2000, Healthy People 2010 may benefit from a small set of leading health indicators that will be of interest, importance and relevance
to the general public, non-health organizations, and traditional public and private health organizations. Leading health indicators can
focus on a small number of key health and social issues that can be brought to the attention of the nation, motivate actions to exert
positive influences over these leading health indicators and provide feedback concerning progress toward achieving the targets set for
each indicator. Furthermore, a small set of leading health indicators can create a national identity for the full-scale implementation of
Healthy People 2010 and expand the traditional Healthy People community to include a wide variety of agencies, organizations,
diverse population groups, community organizations, and individuals.
CHARGE TO THE COMMITTEE
The Institute of Medicine convened a committee to consider the issue of leading health indicators for Healthy People 2010 and to
develop and recommend a minimum of two sets of indicators for consideration by the U.S. Department of Health and Human Services.
The committee received its charge from the department with several opportunities for review and discussion. The initial charge
emphasized that the committee should recommend a minimum of two candidate indicator sets that would (1) elicit interest and
awareness among the general population, (2) motivate diverse population groups to engage in activities that will exert a positive
impact on specific indicators and in turn, improve the overall health of the nation, and (3) provide ongoing feedback concerning
progress toward improving the status of specific indicators. In subsequent meetings between committee members and staff from the
U.S. Department of Health and Human Services, this charge was reviewed and clarification sought where necessary. Specifically, the
committee was informed that the charge also included the development of potential dissemination strategies to promote the leading
health indicators to the lay public and traditional public and private health care communities. It was also established that clear linkages
should be demonstrated between the proposed indicators and the existing full draft of Healthy People 2010, including the two
overarching goals, four enabling goals and 26 focus areas. Finally, the committee received additional direction that the candidate
indicator sets should contain no more^than 10 indicators and that any proposed indicator set should be supported by a conceptual
framework around which the specific indicators could be organized.
OVERVIEW OF INDICATOR SET DEVELOPMENT
This report provides a detailed discussion of the committee's efforts to develop leading health indicator sets that could focus on health
and social issues as well as evoke response and action from the general public and the traditional audiences for Healthy People.
Briefly, three sets of leading health indicators were developed through the standard Institute of Medicine committee process. The
committee followed an iterative approach to guide selection of conceptual frameworks and specific indicators for potential indicator
sets. These efforts resulted in consideration of 13 conceptual frameworks and more than 50 categories of indicators. The committee
then followed a consensus-based approach to facilitate selection of conceptual frameworks and specific indicators. This resulted in
three unique conceptual frameworks and 19 indicators unique to the three proposed sets.
The diverse expertise and experience of the committee members strongly influenced the process of selection of the conceptual
frameworks and indicators. However, the appointed committee is confident about the strengths of the three conceptual frameworks
underlying each of the proposed sets and similarly, the ability of specific indicators within each set to meet the final set of six essential
criteria. The committee is also confident that the three proposed indicator sets are responsive to every aspect of the committee's
charge.
The committee also focused on identification of a set of essential criteria to guide the selection of suitable indicators for each of the
candidate indicator sets. Initially, the committee accepted the nine criteria that had been recommended by the Working Group on
Sentinel Indicators for Healthy People 2010. The committee then decided to expand this initial set of nine to include five additional
criteria. As the committee progressed in its efforts to select appropriate indicators, they shared a growing awareness of the need to
select criteria that would be understandable to the lay public and traditional public and private health care professionals as well as
feasible to implement. Ultimately the committee decided that 14 criteria were too numerous and therefore, not feasible to apply in the
selection of specific indicators. Following an interactive process that also reflected the committee's best judgments and their
consideration of relevant literature and public comment resulted in a smaller set of six essential criteria that were worded in the
simplest and most understandable terms. These criteria then became the essential conditions used by the committee to guide selection
of the final indicators in each of the three proposed sets. The final set of six criteria are presented in the following Table E.l.
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Table E.l Final Criteria Guiding Selection of Leading Health Indicators
1. Worth measuring - the indicators represent an important and salient aspect of the public's health
2. Can be measured for diverse populations - the indicators are valid and reliable for the general population and diverse population groups
3. Understood by people who need to act - people who need to act on their own behalf or that of others should be able to readily comprehend the
indicators and what can be done to improve the status of those indicators
4. Information will galvanize action - the indicators are of such a nature that action can be taken at the national, state, local and community levels by
individuals as well as organized groups and public and private agencies
5. Actions that can lead to improvement are anticipated and feasible - there are proven actions (e.g., changes in personal behaviors, implementation of
new policies, etc.) that can alter the course of the indicators when widely applied
6. Measurement overtime will reflect results of action - if action is taken, tangible results will be seen indicating improvements in various aspects of
the nation's health
Committee efforts then turned toward the identification of plausible, science-based conceptual frameworks around which sets of
leading health indicators could be organized. In addition, the committee identified 50 categories from which indicators could be
selected. These efforts resulted in development of three sets of leading health indicators including (1) a Health Determinants and
Health Outcomes Set, (2) a Life Course Determinants Set, and (3) a Prevention-Oriented Set. Three conceptual frameworks provided
an underlying logic that facilitated selection and organization of indicators within each of the three proposed sets. In addition, the
committee considered issues relevant to dissemination strategies, data collection and analysis, health disparities, potential strategies for
action, and strength and limitations associated with the proposed sets. Table E.2 provides an overview of the specific indicators within
each of the three proposed sets.
Table E.2 Comparative Overview of Three Proposed Leading Health Indicator Sets
Health Determinants and Health Outcomes
Life Course Determinants
Prevention
Physical environment
Substance abuse
Poverty
Poverty
Poverty
Tobacco use
High school graduation
Tobacco use
Physical activity
Health care access
Cognitive development
Childhood immunization
Cancer screening
Hypertension screening
Diabetic eye exam
Health care access
Weight
Physical activity
Health insurance
Violence
Disability
Cancer detection
Tobacco use
Disability
Preventable deaths
Disability
Low birth weight
Preventable deaths
NOTE: Key: Bold = Unique to the set, Italic = Common to two sets. Underline = Common to three sets
DESCRIPTION OF PROPOSED INDICATOR SETS
Health Determinants and Health Outcomes Set
The Health Determinants and Health Outcomes Set is based on extensive research supporting the field model of determinants of health
at the individual and population levels (Evans and Stoddart, 1992). In this conceptual framework, determinants of health are also
considered predictors of health behaviors and health outcomes. Knowledge about how well the nation, a state, a community or an
individual is doing on specific indicators clarifies factors associated with the current health status of this nation and suggests actions to
be taken to further improve the nation's health status. In addition, the proposed set includes a small number of indicators to assess
broad population health outcomes. This provides information about disease morbidity and mortality that require interventions to
improve disease outcomes of diverse U.S. populations.
The proposed Health Determinants and Health Outcomes Set includes eight indicators representative of health determinants: physical
environment, poverty, high school graduation, tobacco use, weight, physical activity, health insurance, and cancer detection. These
indicators have been chosen because they represent some of the most powerful determinants of health for which meaningful action can
be taken at multiple jurisdictional levels, ranging from the national and state levels to individuals and families in neighborhoods and
communities. There are two indicators to address health outcomes. The first focuses on prevention of mortality associated with
intentional and unintentional injuries, while the second addresses the extent to which illness, injury or disability prevents people from
performing important social roles. The indicator set therefore recognizes that just as society has an effect on health, so too the health of
the population has aneffect on the functioning and productivity of society.
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Life Course Determinants Set
The conceptual framework for the Life Course Determinants Set draws from two models regarding the primary determinants of health.
This set integrates the field model, described above, and the life course health development model. The life course health development
model reflects a growing body of evidence that health outcomes and health status follow a developmental process in which current
health status and outcomes are the product of cumulative inputs across the course of life. This framework suggests that at strategic
points throughout the life course, health determinants are susceptible to greatest influence and, in turn, can significantly affect the
subsequent life course. For example, lifelong patterns of tobacco use may be most dependent upon smoking behaviors established in
adolescence. To be most successful in the prevention of death and disability from diseases associated with tobacco smoking, the public
and the health care system should focus efforts most intensely on prevention of smoking initiation and smoking cessation programs
targeted to youth. Similarly, the long-term functional level of an adult who has had a stroke may be primarily determined by the
physical rehabilitation and psychosocial support received in the first few months following the stroke. The Life Course Determinants
Set includes indicators representative of health in a broad social and biological context including substance abuse, poverty, physical
activity, health care access, cognitive development, violence, disability, tobacco use and low birth weight.
Prevention-Oriented Set
The third proposed set of leading health indicators is based on the Prevention Model, which relies on four basic constructs: current
health status, primary prevention, secondary prevention, and tertiary prevention. The Prevention-Oriented Set uses a simple and
conventional structure that encompasses both individual and community-based health activities and the prevention and disease
management activities of the health care delivery system. The prevention orientation itself emphasizes that the general population, in
collaboration with public and private health professionals, should take action to promote health and prevent disease in themselves and
others. Approaches to the achievement of improvements in health behaviors and disease outcomes can be personal, familial or
institutional.
The four categories into which the nine indicators in the Prevention-Oriented Set have been given names that are intended to be
comprehensible to the lay public and diverse population groups. Thus, instead of listing the first category as health status, the category
is, "How are we feeling?" The category of primary prevention is associated with the question "How do we keep ourselves well?"
Secondary prevention is described as "If we are sick, how can we find disease early?" Tertiary prevention is described as "When we
are sick, how do we get the best medical care?" Indicators in the proposed set were selected with a particular emphasis on issues
pertinent to ease of interpretation by the public, availability of data for national, state, local, and community jurisdictions, and the
relation of the indicators to health promotion and disease prevention surveys as well as to morbidity surveys. The specific indicators
include: disability, and preventable deaths as measures of current health status; poverty, tobacco use and childhood immunizations as
primary prevention strategies; cancer screening and hypertension screening as representative of secondary prevention, and diabetes
management and health care access as measures of tertiary prevention.
LINKAGE OF INDICATOR SETS TO HEALTHY PEOPLE 2010
The three proposed leading health indicator sets reflect a shift in emphasis away from simple mortality measures toward a more
complex array that includes health-related quality-of- life, protective health behaviors, risk behaviors, social, and environmental
factors consistent with one of two overarching goals of Healthy People 2010'. to increase the quality and years of healthy life. This
shift in focus away from measures of mortality reinforces the role of the proposed indicator sets in responding to such an expanded
vision of health. Each of the three proposed indicator sets also addresses many of the social, cultural, economic and health care system
issues considered by many to be critical factors in efforts to eliminate health disparities, which is the second of the overarching goals
established for Healthy People 2010. For example, measures of income, education, and access to health care for disease prevention,
detection, and treatment are included in one or more of the sets. In addition, the proposed sets include measures relevant to each of the
six areas identified by the U.S. Department of Health and Human Services Initiative to Eliminate Disparities in Health. These include
cancer screening, diabetes, immunizations, infant mortality, and risk behaviors for cardiovascular and other diseases.
The suggested sets of indicators are also linked to the four enabling goals established for Healthy People 2010. These include
promotion of health behaviors, promotion of healthy communities, prevention and reduction of diseases and disorders, and
improvement of systems for personal and public health. For example, the poverty, health insurance, high school graduation and health
care access indicators can be considered to be representative of a healthy community as well as improved systems for personal and
public health. Similarly, immunization, tobacco, substance abuse, physical activity, and weight are associated with promotion of
healthy behaviors, promotion of healthy communities, and prevention and reduction of disease and disorders.
CROSSCUTTING DATA ISSUES
The committee's selection of three sets of leading health indicators also relied on an analysis of crosscutting data issues. The
committee believes it is essential that the DATA2000 Monitoring System be updated for Healthy People 2010 to ensure that it
continues to be the leading source of comprehensive data for the ongoing monitoring of the proposed leading health indicators and
reporting on the indicators on a timely and routine basis. Additional federal databases may also provide alternative sources of data to
inform the three proposed sets of leading health indicators.
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In the absence of existing data collection efforts, new data collection efforts that will provide data on the indicators as well as permit
multilevel analysis and reporting of key results at the national, state, local, and community levels will be required. This has particular
relevance to data collection and analysis efforts for specific population groups defined by age, gender, race and ethnicity, disability,
socioeconomic levels, geographic locale, sexual orientation, and levels of educational attainment. It will be essential to identify the
need for new data collection efforts that will provide information about the three sets of indicators for diverse population groups prior
to implementation of the full Healthy People 2010 plan and the selected set of leading health indicators. Further, analyses for the
monitoring of changes in the indicators should include data for the total population as well as data for diverse population groups.
Furthermore, to ensure that local or community-based initiatives are the most appropriate and effective to improve the status of the
leading health indicators, data will be required for defined jurisdictional units as well as select population groups within those local
jurisdictions. This reflects the committee's recognition of the importance of an individual's community in influencing the wide range of
health-related behaviors, beliefs, practices, and outcomes considered in each of the three sets of leading health indicators. This is
especially true as the focus of the recommended sets has been broadened to encompass a wider range of factors that influence health,
such as social, educational, and environmental factors, preventive health behaviors, risk behaviors, to health care systems and other
direct biological determinants of health outcomes.
This report also identifies steps the U.S. Department of Health and Human Services can take to ensure the highest quality of data
collection and management. This is of particular importance in cases in which new or expanded data sets will be established to
measure the indicators and analyze the progress that has been made toward achieving the specific targets for each leading health
indicator. The committee encourages particular attention be given to data quality limitations of self-reported data, data validity and
reliability, periodicity and timeliness of data availability, representativeness of data and small-area analyses.
DISSEMINATION STRATEGIES
Experience with leading health indicators during the first two decades of Healthy People suggests that traditional methods of
communication and dissemination are unlikely to be successful in communicating to the general public and motivating public actions
to improve the status of specific indicators. This report includes the committee's suggestions for effective strategies for the
communication and dissemination of information about the leading health indicators, with an emphasis on the role of the U.S.
Department of Health and Human Services as the lead agency to assume responsibility for integration of traditional methods of
dissemination of information with new communications channels such as electronic communication. The committee also suggests that
research on communications and dissemination strategies should be completed before the department finalizes the language for
specific indicators for the selected set of leading health indicators. This research should focus on determination of the most compelling
language that will communicate to the diverse groups of the population and encourage those subgroups to take action. Similarly,
traditional and innovative communications products and methodologies should be evaluated before their inclusion in the full
dissemination protocol for the leading health indicators that will be undertaken by the U.S. Department of Health and Human Services
and its collaborating agencies. The department is also strongly encouraged by the committee to establish an ongoing system of process
evaluation, including audits of communications products and the use of target group profiles of diverse population groups. These
should be developed prior to initiation of the leading health indicator component of Healthy People 2010 and continued for the
duration Healthy People 2010. This will provide the U.S. Department of Health and Human Services with information about the
implementation of different communication strategies as well as assessments of their effectiveness in motivating actions among
individuals and communities to improve the status of specific indicators. This will provide ongoing feedback about the successes and
failures of specific dissemination strategies for diverse population groups and will support modification of these strategies, if
necessary, during the full course of Healthy People 2010.
CONCLUSIONS AND RECOMMENDATIONS
Chapter 3 of this report recommends three sets of leading health indicators for consideration by the U.S. Department of Health and
Human Services along with suggestions for effective dissemination of the selected indicator set to the general public, including diverse
population groups, and the public and private health care communities. The chapter also includes information about potential action
strategies for each of the proposed indicators, and a discussion of the general strengths and limitations of the three proposed indicator
sets. The Committee recognizes the difficulty and complexity of the department's task of selecting a single set of leading health
indicators for Healthy People 2010. In order to facilitate that process this committee makes a number of recommendations and
suggested action steps to be taken by the U.S. Department of Health and Human Services.
Selection ofIndicator Set
The committee recommends that the U.S. Department of Health and Human Services select a single set of leading health
indicators from among the three proposed sets and commit to support fully the implementation of the selected indicator set for
the duration of Healthy People 2010. The Committee recognizes that political and/or policy issues may motivate the U.S.
Department of Health and Human Services to change indicators within the sets. The committee does not advocate for efforts by the
U.S. Department of Health and Human Services to develop alternative sets of indicators comprised of different indicators selected
from each of the three proposed sets. The three sets are based on unique conceptual frameworks and integration of indicators between
sets would likely compromise the internal validity of each of the sets. If the U.S. Department of Health and Human Services must
consider altering the indicators within a set, the committee strongly urges that it is done in such a manner that does not compromise
the internal validity of the conceptual frameworks supporting each of the three sets.
Achieving the laudable goals of the leading health indicator effort to promote the nation's health will be difficult unless department
efforts to promote, evaluate, and disseminate the selected set of indicators are maintained and strengthened. The Committee offers five
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suggestions for steps necessary to support the leading health indicator initiative.
Inter-Agency Collaborations
Leading health indicators will be strengthened by continued collaborations of the U.S. Department of Health and Human Services with
other federal agencies (e.g.. Environmental Protection Agency, U.S. Department of Labor, U.S. Department of Education, U.S.
Department of Housing and Urban Development), private sector agencies, businesses, labor and voluntary groups, state and local
health agencies, and community-based groups and organizations with a shared goal of improving the health of their communities and
thereby improving the health of the nation.
Dissemination Strategies
A comprehensive plan for communication and dissemination of information related to the leading health indicators should be
responsive to the needs of diverse population groups and include both traditional and innovative communication and health behavior
change strategies.
Health Disparities
Data must be available on a consistent, timely, and periodic basis to examine health disparities among the following population
groups: 1) population groups defined by race and ethnicity; 2) population groups defined by income; 3) population groups defined by
age; 4) population groups defined by gender; 5) population groups defined by functional status; 6) population groups defined by sexual
orientation; 7) population groups defined by levels of educational attainment, and 8) population groups defined by geographic locale.
Poverty/Socioeconomic Status
Analysis of every indicator with socioeconomic status or income level as stratification variables will ensure that health disparities
attributable to variations in socioeconomic status are identified, monitored, and corrected.
Data Collection and Analysis
Assuring the availability of appropriate data to monitor the selected leading health indicator sets will include the following actions:
1. Evaluation of data sets for the following characteristics: quality of data, limitations of self-reported data, periodicity and
timeliness of data availability, representativeness of data, and ability to provide small-area analyses,
2. Technical assistance to communities to utilize small-area analysis data sets appropriately in the design, implementation, and
evaluation of local interventions to improve the status of specific indicators, and
3. Determination of the appropriate intervals for data collection, methods of analysis, and frequency of reporting of results for each
of the indicators.
The development of leading health indicators that provide a clearly understandable and recognizable face for the full Healthy People
2010 agenda has enormous potential to exert positive influences on the public's awareness and practice of health-promoting behaviors.
This is especially true if the chosen set of indicators is meaningful to and can be acted upon by the lay public, with an emphasis on
diverse population groups.
This report contains a number of recommendations and suggestions for the Department of Health and Human Services that address
issues relevant to the composition of leading health indicator sets, data collection, data analysis, effective dissemination strategies,
health disparities, and application of the indicators across multiple jurisdictional levels. These recommendations and suggestions also
reflect the committee's belief that achievement of the overarching and enabling goals of Healthy People 2010 is possible only when
national, state, and local health agencies establish collaborative partnerships with members and organizations representative of a wide
array of diverse population groups and communities. These partnerships can yield significant and sustained changes in the health
behaviors and health outcomes of the public. In the presence of collaborative, community-based partnerships, leading health indicators
for Healthy People 2010 can be used as tools to mobilize the lay public and health professionals to become engaged in making
progress toward the health goals for the nation and to do so in a manner that prompts public understanding of and policy actions
related to the important determinants of that progress.
1
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Background and Significance
HEALTHY PEOPLE: THE FIRST DECADE
Healthy People has evolved over the past 20 years to become the nation's health agenda. It encompasseshealth promotion and disease
prevention efforts that are intended to achieve and sustain significantimprovements in the health of all people in the United States. The
conceptual underpinnings of HealthyPeople were first described in a 1979 report from the Surgeon General entitled Healthy People:
The SurgeonGeneral's Report on Health Promotion and Disease Prevention (U.S. Public Health Service, 1979). That report outlined a
set of 5 national health goals that would guide health promotion and disease preventionactivities during the decade 1980 to 1990. The
primary purpose of establishing these health goals was toad vance a small set of measures that could be tracked on a routine basis to
monitor the general status of thehealth of the public (U.S. Department of Health and Human Services, 1998a). These five goals
wereestablished for five distinct age cohorts and included the following:
1. an overall 35 percent reduction in the rate of infant mortality;
2. a 20 percent reduction in the numbers of deaths among children ages 1 to 14 years to fewer than 34 per 100,000;
3. a 20 percent reduction in the numbers of deaths among adolescents and young adults up to age 24 to fewer than 93per 100,000;
4. a 25 percent reduction in the numbers of deaths among adults ages 25 to 65; and
5. a 20 percent reduction in theaverage number of days of illness among those over age 65 (U.S. Public Health Service,1979).
The report described 15 strategies by which these five goals could be achieved by 1990. Each of the 15 strategies, in turn, were
supported by objectives that could be grouped into one of following categories: (1) preventive services delivered by the health care
system, (2) interventions undertaken by governmental and private sector agencies to prevent harm to the public, and (3) personal and
community level activities to promote healthy lifestyles.
The U.S. Department of Health, Education and Welfare (now known as the U.S. Department of Health and Human Services) convened
in June, 1979 a conference in which recognized experts addressed each of the 15 strategic areas for intervention. Fifteen panels of
experts drafted sets of quantifiable objectives that were then published in the Federal Register in fall of 1979 to elicit broad-based
review and commentary from the public and private health care system. Interim and final revisions to 226 objectives representing each
of the 15 strategic areas were completed by the spring of 1980. A target outcome was identified for the 226 objectives and these were
then published in a second document. Promoting Health/Preventing Disease: Objectivesfor the Nation (U.S. Department of Health
and Human Services, 1980). The overriding premise for that report was the need for improvement of the health of all people in the
U.S. during the decade of 1980 to 1990 through the implementation of intervention plans by governmental bodies and private sector
agencies at the national, state, local, and community levels.
Evaluation of progress toward achieving the 226 objectives outlined in Promoting Health/Preventing Disease: Objectives for the
Nation relied on periodic progress reviews and a midcourse review. Both reviews included discussions of the progress that had been
made toward achievement of each of the objectives and the five overarching goals, analysis of shortfalls and problems associated with
implementation of the interventions, and suggestions for modifications to the specific language of objectives or the methods of
intervention. Five periodic progress reviews and the midcourse review were completed by 1996 (National Center for Health Statistics,
1992,1994, 1995, 1996, 1997). A final report summarized the progress that had been made in achieving the five overarching goals as
well as each of the 226 objectives (Journal of the American Medical Association, 1992). That final review revealed that among the
five overarching goals, positive changes had been achieved for infants, children, and adults whereas the goals for adolescents and the
elderly had not been met. Of equal importance, this final report set the stage for development and modification of goals and objectives
for the next decade of the Healthy People including the years from 1990 to 2000.
HEALTHY PEOPLE 2000
The development of priority areas and objectives for the decade from 1990 to 2000 was enhanced by lessons learned during the first
decade of Healthy People. Several significant changes were incorporated into the Healthy People 2000 plan as a result of those lessons
(U.S. Department of Health and Human Services, 1991). Specifically, the five age-based mortality and morbidity reduction goals were
replaced by the following three goals:
1. increase the span of healthy life for Americans,
2. reduce health disparities among Americans, and
3. provide access to preventive health services for all Americans.
In addition, the original 15 strategic areas were expanded, renamed, and reorganized to include 22 priority areas. The entire national
public health community was invited to contribute to the process of determining the priority areas, objectives, and targets for Healthy
People 2000. The total number of objectives increased to 319. Of greater significance was the inclusion of subobjectives to ensure that
efforts to reach special population groups in the United States were emphasized, with a particular focus on reduction in disparities of
health status and disease outcomes. Special targets were set for population groups at heightened risk of morbidity and mortality from
disease including people in certain racial and ethnic minority groups and disabled people.
Another innovation that emerged during planning efforts for Healthy People 2000 was the identification of a smaller set of 47
"sentinel" indicators selected from among the full set of 319 objectives. These sentinel indicators were thought to provide a succinct
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measure of the health of the general population and special populations. These 47 indicators were similar in purpose to the five
overarching goals established for the first decade of Healthy People. These sentinel indicators were conceptually linked to the goals,
priority areas, objectives and subobjectives of Healthy People 2000. The intent was for sentinel indicators to monitor the status of the
health of the general population on a regular basis and inform those federal, state, local, and community agencies involved in Healthy
People 2000. Of equal significance, however, was the idea that the sentinel indicators could be presented to the general public and
non-health care professionals to increase their awareness of. and involvement in. Healthy People 2000 activities (Journal of the
American Medical Association, 1995, U.S. Department of Health and Human Services, 1998a).
It was also notable that Healthy People 2000 included a special objective. Objective 22.1, that addressed issues related to health and
disease surveillance and data systems (U.S. Department of Health and Human Services, 1991). The Centers for Disease Control and
Prevention convened the Committee for Objective 22.1 to accomplish several tasks. First, the committee developed a set of 18 health
status indicators that would allow comparisons of data used by public health officials at the federal, state, and local levels of
government. An electronic inventory of data sets that could be used to monitor Healthy People 2000 at the national level was also
established. This inventory described the various data sets used to establish baseline rates for each of the objectives in the 22 priority
areas in Healthy People 2000. It also suggested alternative data sets that had the potential to be effective monitors of progress toward
achievement of all of the Healthy People 2000 objectives. Particular attention was given to the identification of data sets that were
representative of special population groups. Finally , the committee recommended priority data needs and modifications to existing
data collection systems to ensure the availability of measures of outcomes, risk factors, and processes that could be used in the
planning of prevention programs that would support the Healthy People 2000 objectives.
Evaluation strategies for Healthy People 2000 were similar to those described for the first decade of Healthy People. Periodic briefing
summaries were provided to the assistant secretary for health and human services and were then published in Public Health Service
Progress Review Reports on Healthy People 2000 (National Center for Health Statistics, 1992, 1994, 1997). In addition, a midcourse
review was conducted as a 2-year effort initiated in 1993. That midcourse review resulted in publication of the Healthy People 2000
Midcourse Review and 1995 Revisions (National Center for Health Statistics, 1995).
A summary analysis of Healthy People 2000 results indicated that 13 percent of the 319 objectives had reached or superseded the
target quantifiable measures and an additional 43 percent of the objectives had achieved positive progress toward these measures. The
values for only 2 percent of the objectives remained unchanged from the 1990 baseline values. The proportion of objectives for which
only baseline data were available was reduced to 14 percent. Only three percent of the total of objectives lacked baseline rates, which
was a significant improvement over the 20 percent reported in the midcourse review (National Center for Health Statistics, 1995,
1996, 1997).
Progress toward achievement of the targets for the 47 sentinel objectives was disappointing. The set did not generate focused interest
and attention in the general population or the national public and private health care communities, for that matter. Nor did the
establishment of 47 sentinel objectives prompt intensified intervention efforts by agencies to achieve the projected targets. This lack of
success was suggested to be due to the fact that 47 measures were too many, that they may not have been of significant interest,
especially at the levels of state and local governments, and that they may have lacked political appeal (U.S. Department of Health and
Human Services, 1998a).
HEALTHY PEOPLE 2010
Attention was directed toward the third generation of Healthy People even before the final review of accomplishments of Healthy
People 2000 were disseminated (National Center for Health Statistics, 1997). Experiences from the previous two decades played a
major role in establishing a methodology and time frame for the development of the Healthy People 2010 plan. The selection of 26
priority or focus areas and their related objectives and subobjectives, drew heavily upon results from the periodic summaries of
Healthy People 2000 (National Center for Health Statistics, 1992, 1994), the midcourse review of Healthy People 2000 (National
Center for Health Statistics, 1996), and the final Healthy People 2000 report (National Center for Health Statistics, 1997). It was also
recognized that implementation of Healthy People 2010 would best be considered a dynamic process in which changes to the plan
would occur over time on the basis of the occurrence of one or more of the following events indicated in Table 1.1.
Table 1.1 Factors Stimulating Changes to the Healthy People 2010 Plan
1. Analysis and dissemination of significant findings in the data
2. Improvements in data collection methods and systems
3. Enhancements to the science base, especially in the areas of health promotion and disease prevention
4. Growing awareness of health promotion and disease prevention among traditional health care agencies and health professionals
5. Activities of the general population at the community level
6. Ongoing efforts to monitor the quality of health care services
7. Greater specificity and sensitivity of epidemiological knowledge about disease risk factors and methods of effective intervention
8. The changing demographic profile of the U.S. population that will evolve over the decade
9. Changes in availability and access to health care sendees
Recognition of the anticipated complexity of the Healthy People 2010 development process prompted the establishment of the
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Secretary's Council on National Disease Prevention and Health Promotion Objectives for 2010 in September 1996. In addition, the
Healthy People Consortium began to plan for Healthy People 2010. This consortium includes an alliance of diverse organizations
committed to the nation's prevention agenda including state and territorial, public health, mental health, substance abuse, and
environmental agencies and national organizations representative of the professional, voluntary, and business sectors. A meeting of the
Healthy People Consortium was convened on November 15, 1996, which resulted in publication of Building the Prevention Agenda
for 2010: Lessons Learned (fJ .S. Department of Health and Human Services. 1996). Activities heightened in 1997, with the secretary
of health and human services' first briefing on objectives for Healthy People 2010 followed by a meeting of the Secretary's Council on
National Disease Prevention and Health Promotion Objectives for 2010. This meeting provided an opportunity to discuss in greater
detail the objectives to be established for 2010. The U.S. Department of Health and Human Services published a focus group report on
the utility of FIealthy People 2000 in July 1997 (U.S. Department of Health and Human Services, 1997).
Shortly thereafter, in September 1997, a notice calling for comments on the framework, goals, enabling goals, focus areas, and
objectives of the first draft of Healthy People 2010 appeared in the Federal Register. This resulted in more than 700 comments from
private consumers of health care services, Healthy People Consortium members, members of the U.S. Congress, agencies of state and
local governments, health care agencies, and health professional groups, individual health care professionals, and other diverse groups
and organizations. The Healthy People Consortium reconvened in November 1997 with the specific intent of discussing health
disparities and reviewing the degree of progress in reducing these disparities that the nation had made.
Work groups were established for each of the 26 focus areas to discuss objectives, data issues, and disparities in health among diverse
population groups. This work continued through 1997 and 1998 and focused primarily on identification of the Healthy People 2000
objectives to be continued into Healthy People 2010. and identification of new objectives to be developed. The first draft of objectives
Fox Healthy People 2010 were available for internal review by March 1998. This was presented to the Secretary's Council on National
Disease Prevention and Health Promotion Objectives for 2010 in April 1998 and the Notice of Cali for Public Comment on 2010 draft
was appeared in the Federal Register in October 1998. The public comment period extended through December 1998 and occurred
simultaneously with five regional workshops convened by the U.S. Department of Health and Human Services to elicit comments on
the Healthy People 2010 draft from the health care community, members of special population groups, and interested consumers. A
meeting of the Healthy People 2010 Consortium was held in November 1998 to discuss the implications of results from the public
comment period and regional meetings.
A third meeting of the Secretary's Council on National Disease Prevention and Health Promotion Objectives for 2010 will convene in
April 1999 and will be followed by a Healthy People Consortium meeting in June 1999. Efforts to finalize the Healthy People 2010
plan, including the overarching goals, enabling goals, focus areas, and objectives, will continue through the remainder of 1999 with
the anticipated release of Healthy People 2010 scheduled for January 2000. At present. Healthy People 2010 includes two overarching
goals (increase quality and years of healthy life and eliminate health disparities), four enabling goals (promote healthy behaviors,
promote healthy and safe communities, improve systems for personal and public health, and prevent and reduce diseases and
disorders), 26 focus areas, objectives, and "developmental objectives" that are associated with each focus area but for which current
surveillance systems and databases do not yet provide the requisite quantitative measures. The inclusion of developmental objectives
in Healthy People 2010 is intended to identify new focus areas that are important and to encourage the development of national data
systems through which they can be monitored. It is anticipated that 30 percent of the objectives Fox Healthy People 2010 will be
developmental.
During the past two decades Healthy People has become entrenched within the national, state, and local public health communities as
the driving force behind the nation's health promotion and disease prevention agenda. It has fostered efforts to effect changes in health
status, identify emerging health challenges, and facilitate the development, implementation, and evaluation of interventions to respond
in a timely manner to key and emerging health issues. The full set of Healthy People objectives has been particularly useful to federal,
state, and local public health agencies as they do long-range planning and prioritize programs that are appropriate for their target
populations. Multilevel comparisons of commonly available data foster understanding of those populations at greatest risk and can
suggest priorities for resource allocation. Such multilevel comparisons can also provide cross-sectional and longitudinal analyses of
the health of the nation, highlighting these populations at higher risk of disease and poor health outcomes. Analysis at the level of
detail of specific population groups is imperative if the nation is going to achieve the desired changes in specific objectives within
each of the 26 focus areas for all people in the United States. The 26 focus areas, objectives and developmental objectives, without
question, will continue to guide efforts to plan, implement, and evaluate health promotion and disease prevention interventions for the
entire population of the United States.
LEADING HEALTH INDICATORS
The breadth of Healthy People 2010, however, has the potential to overwhelm and perhaps, discourage individuals, voluntary
organizations, community organizations, and businesses from participation. Similar to the five key measures in the first decade of
Healthy People and the 47 sentinel indicators established for Healthy People 2000, Healthy People 2010 will benefit from a small set
of leading health indicators that will be of interest, importance and relevance to the general public, non-health organizations, and
traditional public and private health care communities. Leading health indicators have the potential to significantly increase the impact
of Healthy People 2010 by establishing a small number of key health topics that can (1) be brought to the attention of the nation, (2)
motivate actions to promote positive changes in these topics, and (3) provide ongoing feedback about progress toward achieving the
desired changes in these topics. Such a set of leading health indicators can focus national attention on a limited number of measures
that have relevance to. and can be acted upon by. the general public, public and private policy makers, and health and science
professionals. Furthermore, a set of leading health indicators can create a national identity Fox Healthy People 2010 and can expand the
traditional Healthy People community to include a wide variety of agencies, organizations, diverse population groups, community
organizations, and individuals from outside as well as within the health care community. To achieve their full potential for success,
communications strategies for leading health indicators must be appropriate and effective for the general population and diverse
population groups, especially those that may not be reached by traditional health care communications campaigns such as elderly
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people, members of racial and ethnic minority groups, members of socioeconomically disadvantaged groups and disabled people.
In preparation for the development of a set of leading health indicators, the U.S. Department of Health and Human Services convened
a work group in 1997 whose members included 22 individuals from its Office of Public Health and Science, U.S. Public Health
Service agencies and other agencies of the U.S. Department of Health and Human Service agencies. This work group was charged
with preparing a background paper that would include information on the history of the Healthy People initiative, provide the rationale
for identifying and using leading health indicators, and describe the potential uses and applications of such indicators (U.S.
Department of Health and Human Services, 1998a). In addition, this document provided an overview of existing sets of leading health
indicator sets, discussed the theoretical underpinnings for these sets, suggested nine criteria to guide selection of potential indicators,
and reviewed issues concerning data availability and analysis. The U.S. Department of Health and Human Services then asked the
Institute of Medicine to convene a committee to consider the issue oflcading health indicators and to propose a minimum of two sets
of indicators from which the department could choose the leading health indicator set for Healthy People 2010
2
Approach to Development of Leading Health Indicator Sets
To undertake the study requested by the U.S. Department of Health and Human Services, the Instituteof Medicine appointed a tenmember committee in May 1998. Members were selected for their cxperiiscand experience in multiple disciplines, including public
health and health policy, health communications,epidemiology, health care access, health behavior change, and clinical care. The
committee met five timesbetween May 1998 and March 1999. The first meeting of the committee included a workshop
involvingparticipants from many of the state and local government agencies who had been involved with HealthyPeople since its
inception in 1979. In conjunction with its fourth meeting in January 1999, the committeeconvened a public hearing to elicit comments
and recommendations from the public and private health carecomm uni lies concerning leading health indicators for Healthy People
2010. In addition, the committeeprepared two interim reports which were published in August 1998 and December 1998, respectively
andwhich provided updates on the committee's progress.
As a result of its work, the committee developed three candidate sets oflcading health indicators forconsideration by the U.S.
Department of Health and Human Services. This process had three major phases:
1. Development of criteria for suitable indicators.
2. Development of potential conceptual organizing frameworks and indicator categories, and
3. Selection of final candidate indicator sets.
The committee completed a number of activities to support the process of reaching consensus on the recommendations for three
candidate sets of leading health indicators. Briefly, these activities includ <1:
1. clarification and acceptance of the charge to the committee,
2. review of relevant literature, especially alternative efforts focused on health report cards and indicators considered to be
representative of the health and well-being of communities,
3. development of a set(s) of essential criteria against which selection of potential leading health indicators could be assessed,
4. participation in regional meetings convened by the U.S. Department of Health and Human Services to elicit commentary on the
selection oflcading health indicators for Healthy People 2010,
5. consideration of public comments submitted to the Institute of Me/: cine and the Department of Health and Human Services
concerning leading health indicators.
6. evaluation of 11 conceptual frameworks to guide the development f leading health indicator sets,
7. preparation of two interim reports describing the committee's process and efforts,
8. conduct of a public hearing during July 1998 and January 1999. respectively, to elicit further comments on leading health
indicator sets, and
9. final selection of conceptual frameworks and candidate indicator .sci>.
A brief description of each of these activities is provided in the foil owing na rrative.
CHARGE TO COMMITTEE
The committee received its charge from the U.S. Department of Health and Human Services and had several opportunities for periodic
review and clarification. The initial charge emphasized that candidate k . ling health indicator sets should (1) elicit interest and
awareness among the general population and diverse population groups, (2) motivate these diverse population groups to undertake
activities to improve the status of specific indicators and thereby improving the overall health of the nation, (3) provide ongoing
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seraiao it un and making it happen!
*
A Guide for
Equity Gauge
Design and Implementation
Setting it up and making it happen!
A Guide for Equity Gauge Design and Implementation
BACKGROUND
This guide has two primary purposes. The first is to provide existing and potential
individual Equity Gauges with some guidance in the design, planning and
implementation of their strategies and actions. The second is to ensure some
commonality around the key principles and concepts of Equity Gauge design between
different individual gauges - an important requirement for an effective and cohesive
global alliance of Equity Gauges.
This guide has been developed by a "GEGA core group”1 funded by the Rockefeller
Foundation, and follows field testing in Chile, Uganda, South Africa and Kenya. It also
builds on work conducted by the Global Health Equity Initiative (GHEI) and their book,
"Challenging Inequities in Health"2. Finally, it has benefited from feedback and input of
the all gauge members of GEGA.
1 Core group members responsible for drafting this guide were: David McCoy (Health Systems Trust,
South Africa), Meg Wirth (Rockefeller Foundation), Paula Braveman (University of California), Jeanette
Vega (), Antoinette Ntuli (Health Systems Trust, South Arica), Davidson Gwatkin (World Bank), Tim*
Evans (Rockefeller Foundation), Pat Naidoo (Rockefeller Foundation) and Mushtaque Chowdury (BRAC).
2 Challenging Inequities in Health: From Ethics to Action. 2001. Edited by Tim Evans, Margaret
Whitehead, Finn Diderichsen, Abbas Bhuiya and Meg Wirth. New York: Oxford University Press.
2
SECTION 1: THE PRINCIPLES OF EQUITY GAUGE DESIGN AND
IMPLEMENTATION
The importance of equity in health and health care is not new. For example, equity was
listed as one of the key principles of the 1978 Alma Ata Declaration on Health for All.
International health and development agencies, researchers and activists have been
pointing to inequities in health and health care between different countries, between rich
and poor, and between men and women, for many years.
So what is different or distinctive about an Equity Gauge?
The first distinction is that an Equity Gauge is an active approach to monitoring and
addressing inequity in health and health care. It moves beyond a mere description or
passive monitoring of equity indicators to a set of concrete actions designed to effect, real
and sustained change in reducing unfair disparities in health and health care. This entails
an on-going set of strategically planned and coordinated actions that involves a range of
different actors who cut across a number of different disciplines and sectors. It is not a
typical health research project or even limited to actions in the public health domain.
The second distinctive feature of an Equity Gauge is that it is explicitly based on 3
"pillars of action", each considered to be equally important and essential to a successful
outcome, and which should all be represented in both the design and implementation of
an Equity Gauge. The three pillars are:
• Advocacy
• Public participation
• Measurement and monitoring
An Equity Gauge is therefore an approach consisting of a set of actions, and is not, as the
name might suggest, just a set of measurements.
3
Action and Change
Equity Gauge
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Although this set of three actions is portrayed as a set of independent pillars (Figure 1), in
practice, they overlap and inter-connect with each other. For example, the selection of
equity indicators to measure and monitor should be informed by the views of community
groups and by a consideration of what would be useful from an advocacy perspective. In
turn, the advocacy pillar relies reliable indicators developed by the measurement pillar
and may involve community members or public figures.
Another important feature of the three pillar design of the Equity Gauge is that they do
not relate to each other in any temporal sequence. Often research projects tend to collect
information, disseminate it and then undertake advocacy activities in that order. This
linear approach to changing policy or affecting change has often been found to be
ineffective. In an Equity Gauge, the actions of all three of its pillars should be happening
concurrently.
Pillar 1: Advocacy
This pillar refers to a broad set of actions designed to lead to real change in levels of
inequity in health and health care. Effective advocacy is increasingly being recognised as
a challenging and creative skill that researchers, health professionals and public health
initiatives should be equipped with. An ideal Equity Gauge would incorporate and
develop the skills and imagination required to raise the profile of equity in health policy
and planning, and to turn data and information into appropriate action.
Advocacy actions can take form in a number of ways:-
4
> Effective and strategic dissemination of information, education and communication
(IEC) materials3
> The construction of convincing and effective arguments, policies, proposals and
recommendations for improving levels of equity
> Direct engagement and active lobbying of policy makers, decision-makers and other
potential change agents
> Empowering the poor and disadvantaged, and their advocates, with knowledge, skills
and other resources
> Civil society campaigns and challenges to policies / actions designed, or likely, to
lead to greater inequities
An Equity Gauge is not expected to engage in all of the types of advocacy actions listed
above, as they may not all be appropriate in a given setting. For example, direct
challenges by civil society may not be strategic if a more co-operative approach with
government is likely to be more effective. What is important is that advocacy should
extend beyond a passive and unimaginative dissemination of information on levels of
inequity.
The targets of advocacy may also vary from situation to situation. In many instances,
policy and decision makers (the government as a whole, ministers and parliamentarians
etc.) will be critical advocacy targets to help ensure that equity is a political priority. The
civil service and health sector bureaucracy may also be an important target, as it has
been found that even in counties with a pro-equity policy environment, inequities may
continue to persist because of poor policy implementation. In countries where
government is weak, donor agencies and multi-lateral organisations such as the World
Bank may be important. It is also important to see the advantaged and rich sections of
society as being important targets of advocacy - if redistribution is to occur in pursuit of
equity, gaining as much support and understanding from those who are advantaged and
privileged may be very important to mitigate potential resistance to redistribution.
Finally, there may be other stakeholders with a vested interest in opposing change in
favour of equity - for example, private medical insurance companies may oppose
attempts to abolish individual risk-rating.
Pillar 2: Public participation
This pillar refers to the involvement of community groups and stakeholders in health
policy formulation and health sector reform, as well as the principles of community
empowerment (moving away from the notion of the poor being passive beneficiaries of
pro-equity and developmental initiatives), bottom-up development and public
accountability.
Community groups and stakeholders include the general public, with a particular
emphasis on the poor, the illiterate and the impoverished, and the community-based
organisations (CBOs) and non-government organisations (NGOs) that represent them.
' This includes appropriately packaging IEC in different ways for different audience groups.
5
The rich and powerful members of a society are also stakeholders who must be engaged
if inequities are to be reduced through redistribution.
Other important actors include other religious organisations, trade union organisations,
traditional leaders, women’s organisations, civic groups, human rights agencies and
academic institutions. Health workers and community health structures such as clinic
committees and hospital boards might be important group to involve. Finally, journalists
and the media (print, radio and television) are an important constituency whose
participation in an Equity Gauge should be encouraged.
In terms of actions, the 'public participation' pillar might include using CBOs to help
determine appropriate measures of inequity; facilitating discriminated and disadvantaged
community groups to express their health needs in their own words as part of an
advocacy strategy; employing 'participatory research' techniques in the measurement and
description of inequities; and actively encouraging the media to take an interest in health
policy and health systems.
Pillar 3: Measurement
This pillar refers to the identification of inequities that are important for an Equity Gauge
to describe, measure and monitor.
Part of identifying the inequities that are relevant to an Equity Gauge is deciding on the
'population groups' that form the basis of the inequities. This is because measures of
inequity have to be framed in terms of comparisons between groups that are 'advantaged'
versus groups that are 'disadvantaged. Population groups can be constituted in a variety
of ways, and an Equity Gauge should identify the most relevant groups for comparison:
r- Socio-economic status (e.g. comparing the health status differential between socio
economically advantaged and disadvantaged groups)
> Race, religion, language and / or ethnicity groups
> Gender
> Geography and spatial location (e.g. comparing urban and rural populations, or
different states or provinces in a country)
> National origin (e.g. the differential between immigrants / refugees with local
nationals)
> Sexual orientation
> Age (the elderly and children are often at a disadvantage in many societies)
> Disability
In addition to comparisons between different population group categories, measures of
inequity can be reflected according to various dimensions of health:
• the underlying determinants of health and poverty
• health outcomes
• health financing
• access to health care
6
•
•
quality of health care
consequences of ill health
An Equity Gauge needs to then determine how it will actually measure these health
inequities. While there are hundreds of indicators that can be selected and measured to
describe inequity, the point about an Equity Gauge is less to do with painting a
comprehensive and detailed picture of health inequities, than it is with producing enough
data, that is reliable and valid, to influence change.
While the monitoring of equity is typically done through the collection of quantitative
indicators, 'inequities in health' can also be described in other ways. For example, the
problems that the poor and marginalised experience in accessing health and the
devastating consequences of ill health on the socio-economic status of families can
sometimes be better described through the use of descriptive or qualitative information.
Not only can this describe the situation of inequity and the impacts of inequity, they also
provide useful advocacy material.
Using a case study approach to describe the situation of health and health care in a
particularly under-resourced and impoverished area can also act as a powerful lens
through which health policies and health systems reforms can be evaluated in terms of
their impact on improving the health care of the poorest and most marginalised.
In some situations, an Equity Gauge may not have to collect new data - if enough data
and information of acceptable quality already exists, an Equity Gauge might concentrate
more on the analysis and use of existing data to support advocacy.
7
SECTION 2: AN EQUITY GAUGE APPROACH TO EQUITY AND HEALTH
There are different definitions of and conceptual frameworks for equity and inequities in
health and health care. In order to establish a strong global alliance of Equity Gauges, it
would be important for Gauges to share underlying principles and theories of equity and
health inequalities.
An Equity Gauge places health equity squarely within a larger framework of social
justice. While some health variations between people are inevitable (most notably the
fact that an elderly person will generally have less good health than a younger person),
many health inequalities are avoidable and associated with unjust social constructs. It is
these inequalities that are unfair, unjustifiable and avoidable that Equity Gauges are
concerned with.
An Equity Gauge perspective therefore means striving towards a world in which
disadvantaged population groups (whether defined by age, gender, race-ethnicity, socio
economic class or residence) can achieve their full health potential, as indicated by the
health standards of those groups in society who are most advantaged. It calls for
affirmative and preferential action to improve the health of those with the poorest health
and who face the greatest obstacles to achieving their full health potential.
Placing the Equity Gauge within the larger framework of social justice is primarily a
moral consideration based on humane and ethical values. It also arises out of the
empirical evidence in both rich and poor countries, that health is closely associated with
social position, and the underlying political, economic and cultural causes of social
position.
Poverty and marginalisation
In all countries and situations, poverty and marginalisation are underlying and
fundamental causes of inequities in health. Poverty results in certain groups being unable
to access the basic needs of life, and is accentuated by marginalisation through exclusion
due to factors of geography, ethnicity, language, race, disability or illness. Part of the
answer to redressing health inequities therefore lies in eliminating structural poverty,
tackling racism and prejudice and making the opportunities of society more accessible to
the excluded. In addition, ill health and its consequences is also a potent generator of
poverty, emphasising the importance of health interventions as a means of poverty
reduction.
Educational opportunity
In country after country, inequalities in health are robustly associated with educational
attainment. Those with higher levels of education enjoy greater life expectancy and lower
levels of ill health or disability compared to those with less education. Moreover,
education attainment exerts a strong influence on income and standards of living. As a
particularly modifiable determinant of health, improved education and literacy levels of
disadvantaged and marginalised groups is thought to be an effective strategy for reducing
health inequities.
8
Gender
Gender is a key 'social stratifier’ that interacts with other factors like economic class or
race because the broad social and economic determinants of health affect men and
women differently. For example, occupational roles carrying different health risks may
be assigned differently between men and women. Various social and cultural
expectations and constraints can also shape the lives of women differently from men.
Health systems and health care
Although factors outside the health sector are key determinants of health inequities, the
health sector plays a pivotal role in health equity. Through promoting good health, and
providing accessible, appropriate and comprehensive PHC to marginalised groups, health
systems can do much to reduce health inequalities. Conversely, and all too often, health
systems without a focus on equity have the potential to exacerbate or create health
disparities by neglecting the needs of vulnerable populations and ignoring cultural,
physical and financial barriers to accessing health care.
9
SECTION 3: CONTEXTUAL MAPPING
An important aspect of Equity Gauges is that they are contextualised. There is no
standard formula or recipe for an Equity Gauge. An appropriately designed Equity Gauge
is one that fits the circumstances, needs and conditions of a given country, region or city.
This document merely describes the general principles, approaches and characteristics of
Equity Gauges, However, in order to assist Equity Gauges to develop their plans, a set of
generic questions on the social, political and economic context have been formulated. By
answering these questions, it is hoped that Equity Gauges will be stimulated to think
through the many complex and challenging issues that are inherent in any initiative
designed to impact on equity and promote justice.
3.1 The general state of inequity
This section is designed to sketch out the broad picture of inequity and injustice. It should
help to identify andjustify the selection ofpopulation groups that are to be compared
against each in order to describe and quantify inequities in health.
> What is the degree and extent to which your country, region or city is socio
economically stratified? In other words, to what extent are there class divisions, and
how large is the differential between these classes? What have been the general trends
in socio-economic equity over the past 50 years? Has the country seen increasing or
decreasing inequities? What are the underlying causes of this trend?
> Are there any identifiable populations who are socially and politically discriminated
against or persecuted? Are any groups marginalised or disadvantaged on the basis of
gender, religion, race, language, ethnicity or sexual orientation? If so, who are they,
what is the size of these groups, what is the nature of their discrimination /
persecution / marginalisation, how severe is it, what evidence is there of this and what
are their historical roots?
> Is there a rural-urban divide in terms of wealth and poverty? Are the interests and
needs of the rural population adequately represented in government? Is this reflected
by inequities in health between the rural and urban populations?
3.2 Government
Th is section is designed to sketch out the nature ofgovernment which may help inform an
appropriate advocacy strategy and prompt Equity Gauges to think how best they can
engage with 'government' to promote pro-equity change and action.
> What is the system of government and electoral representation? Is there democratic
representation through fair and free elections? Is there "good and just" governance? Is
there a culture of transparent and accountable government?
10
To what extent would the government support the objectives of an Equity Gauge and
be responsive to its findings and recommendations? Is it likely that the Equity Gauge
will be able to promote equity through an open and constructive dialogue with
government?
> Within government, to what extent is health appropriately considered a priority?
What proportion of GDP and the government budget is spent on health care and other
social sector services? Should advocating for a higher proportion of government
spending on the social sector be linked to efforts to reduce inequities in health?
> What health equity issues are on the “radar screen” of policy-makers? What important
health equity issues aren’t on the agenda but should and could be with reasonable
effort in the near future?
Is there an independent legislature (or other body) with the responsibility, authority
and procedures for monitoring the role and performance of the executive arm of
government? Could it be persuaded by an Equity Gauge to act as advocates on behalf
of the poor and marginalised in society? If so, how can they be reached and lobbied?
3.3 Other decision-making and power-brokering institutions
In some countries, the formal structures of government may be weak or disempowered.
This section is designed to prompt Equity Gauges to consider other targets for their
advocacy strategy.
> To what extent are social, public and economic policy decisions influenced by
external agencies such as the WB or IMF? How much of social sector spending
comes in the form of external aid / assistance? Is there an externally imposed
Structural Adjustment Programme in place, and to what extent does this programme
reflect equity concerns? Should donors or multi-lateral agencies be a target for Equity
Gauge advocacy initiatives?
> Are there other powerful or influential non-governmental institutions that need to be
considered as targets for advocacy in favour of greater equity in health? Who might
be your allies and who might be your opponents?
3.4 The advocacy and public participation environment
This section is designed to sketch out other aspects of the environment within which an
Equity Gauge would operate. It hopes to identify potential collaborators, synergies and
levers to an effective advocacy strategy.
Judicial and legal system
> Is there a human rights culture or a commitment to any conventions or declarations on
human rights? What international conventions or declarations on human rights (which
11
could be used as an advocacy lever) is your country, region or city a signatory of?
Have these been officially ratified?
> Do individuals and communities have any constitutional or legal rights to their basic
social and economic needs? To what extent is recourse to the courts a viable method
of advocacy in favour of the poor? Do the poor have access to legal representation?
Could this form the basis of an advocacy strategy for the Equity Gauge?
Is there an independent and functional judiciary? How sympathetic is it to the plight
of the poor and discriminated? Could it be persuaded to advocate on behalf of the
poor and marginalised in society? If so, how can they be reached and lobbied?
Other non-governmental agencies and initiatives
Is there a vibrant non-govemment sector in the city, region or country? Are there
other groups or initiatives working on human rights, poverty alleviation and social
justice who might be potential collaborators of an Equity Gauge? For example, if
there are groups suffering from discrimination, persecution or a denial of basic human
rights, are there efforts, initiatives or movements designed to overcome this?
Do any of the following groups offer the possibility of working as partners to the
Equity Gauge or as advocates for improved equity in health: religious organisations,
trade unions, women's groups and academic institutions?
The media
> Is there a free press / media? How sympathetic is the press / media to the plight of the
poor and discriminated? Does it play a role in upholding fair and accountable
government? How can the media be invited to participate in the Equity Gauge?
Is there a growing information and communication gap between the poorer and richer
sections of society? To what extent is low literacy a barrier to the poor accessing
information? How can IEC from an Equity Gauge be best communicated to the poor
and marginalised through the mass media?
3.5 Macro-economic environment and public policy
This section is designed to sketch out the broader economic and public policy
environment which may help identify some of the underlying causes of health inequities
as well as help inform appropriate recommendations for reducing inequities.
> How rich is the country, region or city? For example, is it a high, middle or low
income country and what is its GDP? What is the stability and growth of the country's
economy? What proportion of total government spending is used on servicing debt re
payments? Is this hampering the capacity of government to strengthen social sector
services, particularly those targeting the poor and marginalised?
12
> What is the ideological / theoretical background of the country’s economic and public
policy? To what extent is equity a key objective of public policy, and to what extent
should economic and public policy be challenged from an equity perspective? For
example, to what extent is public sector policy and macro-economic policy neo
liberal and to what extent does the notion of an interventionist welfare state exist?'
3.6 The health system
This section is designed to sketch out the health sector in more detail.
> How equitable is the health care sector? What evidence and information currently
exists to demonstrate the state of inequity in health?
> To what extent is the health care system horizontally fragmented? For example, is
there a two-tier or three-tier health care system? Do the poor and the rich use different
health care services / systems?
> What is the size of the private health care sector? Has it grown or shrunk in the
country? What effect does it have on the state of inequity or equity in health and
health care?
Have there been any significant health sector reforms in the country over the past 15
years, and what were they? Has this led to a worsening or an improvement in health
and health care inequities? Where have these reforms come from? What are the key
upcoming issues in health policy-making? Are there any future policies or reform
efforts that are being planned, and which may have equity implications?
> Is decentralisation and / or devolution of the health care system happening or being
planned? What effect has this had or will have on health inequities?
> How is health financing organised and how progressive is it? Have there been
changes in the way health care is financed, and have they been more progressive or
regressive? Where and how are decisions about health financing made, and should
they be a target for Equity Gauge advocacy actions?
> To what extent are marginalised groups provided with an opportunity to influence
decision-making within the health system? Do clinic committees and hospitals boards
offer a formal platform and mechanism within the health system for promoting the
needs of the most disadvantaged and marginalised?
13
4.1 What inequities will the Equity Gauge focus on?
The population groups
In order to help choose an appropriate focus based on the contextual map, the following table is designed to help Equity Gauges to
identify and justify their selection of population groups to focus on. NB. This table is not constructed to he filled in, but merely
represents a framework and template to assist Equity Gauge design.
Categorisation of
population groups
Socio-economic:
Race and / or ethnicity:
Religion:
Language:
Gender:
Geography and spatial
location:
National origin (e.g.
immigrants / refugees
versus local nationals):
Sexual orientation
Age
Disability
Disparities in health outcomes
(magnitude of difference between
advantaged and disadvantaged
group(s))
High
Moderate
Low
Size of disadvantaged group
(proportion of the overall
population that comprises the
disadvantaged groups)
Low
Moderate
"High
Public awareness (degree of public
attention paid to health of
disadvantaged group
High
Moderate
Low
Dimensions of health
Having identified the type(s) of population group(s) that are to be the focussed upon, the following table is designed to help Equity
Gauges determine the dimensions of health inequity that will be focussed upon. NB. This table is not constructed to be filled in, but
merely represents a framework and template to assist Equity Gauge design.
Dimensions of
health
Type of
Population group
(to be filled in)
Underlying health
determinants
- Socio-economic
- Behavioural
- Occupational
- Education
- Environmental
Health status
Health care financing
16
Access to health
care
Quality of health
delivery:
e.g. MCH
e.g. communicable
diseases
e.g. trauma
e.g. mental Health
The consequences
of poor health on
social and
economic status
4.2 Planning for effective advocacy (Pillar 1)
Based on the contextual mapping exercise and the focus of health inequities identified in the preceding section, the following table is a
template framework to assist Equity Gauges to map out their advocacy strategy. NB. This table is not constructed to be filled in, but
merely represents a framework and template to assist Equity Gauge planning.
Advocacy actions
Effective and
strategic
dissemination of
IEC materials
Constructing
convincing and
effective arguments,
policies, proposals
and
recommendations
for improving levels
of equity
Direct engagement
and active lobbying
with policy makers
and decision-makers
Empowering the
poor and
disadvantaged, and
their advocates, with
knowledge and
other resources
Actors
Who are your allies
and potential partners
in pursuing these
activities? Who might
be your opponents?
Strategy
What are the key
action points, how will
they be implemented
and which groups will
be targeted? How will
the media be used?
Resources required
What resources are
available and what
additional financial
and human expertise
are needed?
Outputs
Timeframe
Civil society
campaigns and
challenges to policies
I actions designed,
or likely, to lead to
greater inequities
Other
18
4.3 Planning for effective public participation (Pillar 2)
The plan and actions for effective public participation overlaps with the plan and actions for advocacy. The following table may
duplicate some information from the table above, but should help to provide a holistic and analytic map of an Equity Gauge's public
participation strategy. NB. This table is not constructed to be filled in, but merely represents a framework and template to assist Equity
Gauge planning. Some useful generic questions to consider in the use of this table are:
> What amount and proportion of time and funds will be allocated to working with each community groups and promoting public
participation?
> To what extent can your Equity Gauge be influenced by the community’s agenda? For example, health service planning and policy
are not necessarily priorities for the most marginalised, for whom poverty reduction may be the biggest priority (as well as the
most vital contribution to promoting equity in health).
> How will you overcome the potential power imbalance between community groups and academics / professionals?
Community groups
Rationale and purpose for choosing
this community group
Involvement with the Equity Gauge
The general public
CBOs or community
representatives of the poor and
marginalised_______________
CBOs or community
representatives of the rich and
advantaged_______________
Civic organisations and
consumer groups
Women's groups
Religious organisations
Trade unions
Traditional leaders
19
Timeframes and outputs
Health workers
Allopathic public
Allopathic private______
Traditional health practitioners
Health science students
Clinic committees, hospital
boards etc.
Media and journalists
Other
20
4.4 Measurement (Pillar 3)
Having selected the types and dimensions of health inequity that your Equity Gauge will be focussing on (section 4.1), the following
table is designed to elaborate the actual data and actions required to fulfil the measurement pillar of the Equity Gauge. NB. This table
is not constructed to be filled in, but merely represents a framework and template to assist Equity Gauge planning
Some useful questions to consider when using this table are:
> Why have the following indicators been selected?
> Was / will input from different stakeholders be solicited on the choice of indicators? How meaningful are the selected indicators
likely to be to decision-makers and the public? Will information on these indicators be likely to move people to take action?
> Have you considered “participatory” approaches that combine the goal of collecting information with promoting stakeholder
involvement?
Selection of quantifiable and measurable indicators
Population
group
Dimension of health
Selection of quantitative
indicators
Source and methodology of data
and information
Quality and reproducibility of data
Are the selected indicators measurable, of
acceptable quality and possible to use over
time so that you can evaluate the effects of
policies or plans to reduce inequity?
Qualitative data and information
What forms of qualitative data and information will be used in the Equity Gauge? Will descriptive case studies, in-depth interviews
and focus group discussions form pail of the data collecting exercise of the Equity Gauge?
Appendix 1: The Diderichsen model
Many analyses of health inequities have used Diderichsen’s social determinants
framework which consists of four broad mechanisms that play a role in generating health
inequities. The way it works is that social stratification (I) leads to a separation of people
into different social positions. These differential social positions in turn lead to a
differential exposure to causes of illness, disease or injury (II), a differential susceptibility
to causes of illness, disease or injury (III) and a differential consequence of illness,
disease or injury (IV). These differential social consequences of ill health then have the
consequence of reinforcing social stratification, thus setting into place a vicious cycle of
increasingly widening disparities.
For example, low income workers are more exposed (I) to occupational injuries and
unsafe working environments than high income professionals. Or, a malnourished child is
more susceptible (II) to developing severe respiratory complications following a measles
infection, than a well nourished child. And finally, in societies with inadequate social
security nets, the consequence (IV) of the cost of health care on a poor household can be
further or complete impoverishment, and thereby a worsening of social position.
SOCIETY
INDIVIDUAL
I
A
Social position
B
► H
The Social
and Policy
Context
III
Specific exposure
C
EE
Disease / injury
D
IV
------- -------------
____ t_____
Social consequences
(handicap)
<
I
What is also important about this model is that each of the mechanisms
described above can be countered by specific pro-equity policies or by a
modification of the social context. These are to influence and modify the pattern
and extent of social stratification (A), to preferentially decrease exposures
amongst the poor and vulnerable (B), to preferentially decrease differential
susceptibility amongst the poor and vulnerable (C) and to prevent unequal social
consequences (D).
Appendix 2:
23
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PROGRAMME SCHEDULE FOR ORIENTATION ON
RIGHT TO HEALTH CARE IN AN URBAN CONTEXT
Date: June 23, 2006
Time: 9.30 - 5.00
Venue Fedina-Navachetana, No. 154, Anjaneya Temple Street, Domlur Village,
Bangalore - 560 071, Phone No. 080-25353190, 2535363, 9886648508 ’
Objective (en>rf esfrisb):
1.
2.
3.
To provide information regarding the structure and functioning of the urban
health care system, drtti
?5frfo*
To orient the participants to ‘right to health’ and the ‘right to health care’
campaign, ‘esdjserijd
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To explore how the participants could integrate ‘right to health’ as part of their
work. e3rfjserfad
ipsrfnsh
wd dzJr
Schedule
arfcf):
09.30-10.15: Introduction of participants and listing of expectations [NT/ EP]
sjrariidtoxbrfsSd
ps ssoiaErrarfaoci add
10.15-11.15: Understanding health (including various dimensions of health) [SJC]
a
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11.15-11.30: Tea Break
11.30-12.15: Understanding determinants of health [EP]
12.15-01.15: Understanding Tight to health’ & Tight to healthcare’ campaign [NT/ PS]
>
__ >___ 4.
■
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.
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.
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01.15-02.00: Lunch Break
02.00-02.45: Structure and functioning of the urban health care delivery system [SJC]
2>
02.45-03.00: Tea Break
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03.00-03.40: Group Exercise [PS]
03.40-04.00: Consolidation of responses and linking it to the day’s theme [EP]
04.00-04.45: Brainstorming about how the participants could integrate Tight to health’
as part of their work; Specific follow-up action points. [FEDINA]
A
04.45-05.00: Feedback and Evaluation [CHC team]
[PS: Prasanna Saligram, SJC: S. J. Chander, EP: E. Premdas, NT: Naveen Thomas]
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List of Thematic Areas
is merely a listing of key issues wherein
Universal access to comprehensive health care for all
Cost, availability and accessibility
National Health Policy
Pharmaceutical Policy
Population Policy
Intellectual Property Rights
Equity in Health
Equitable access to services
Quality of public health care services
■’
•
■
■
■
■
■
-
I- •
Health sector reforms and globalization
• Globalisation and Health
. In the context of globalization - primary health care
■ Impact of globalization on health
health and
and health
health care
care in India, South East Asia and
developing countries.
Primarv Health Care
: tx:?-»>—” ‘bis “
■
ii
Ii
for the last 54 years?
Global scenario
Availability of essential drugs
Non-Communicable diseases into the primary care
Resurgence of Communicable Diseases
■
■
■
■
Private health sector
• Regulating the private health sector and accreditation
- Role of the private sector in development and implementation of health care
■
■
■
programs at the community level
Role of nursing homes in health care including accreditation
Role of private sector in development initiatives
Bio Medical Waste Disposal
Women and health
.
■ Violence against women as a public licalth and human rights issue
. Reproductive health and quality' of care*. We were also interested in the issue of
malnutrition of women throughout the lifecycle and feel that it should be included
in any discussion on 'reproductive health? For instance, there is considerable
evidence for the impact of poor maternal height, pre-pregnancy weight and low
gestational weight gain on the incidence of low birth weight and maternal
mortality, however the issue of nutrition has not found adequate attention within
either AnteNatalCare or adolescent health programmes. It may be also be
worthwhile to include lite issue of'malnutrition' in general as a separate topic.
■ One of the significant issues in the south Asian region is the incidence of low
birth weight and we feel that it should be included in any list of key issues for this
I
•
region.
Reproductive Health and Quality of Care
HIV/AIDS
■ H1V-A1DS as a rights issue
- Response to HIV/ AIDS care and support issues
Health Financing & Health care insurance
Research and ethics
of health world-wide and relevance to the Indian
■ Research on different systems
health svstem*
■ We would also like to emphasise the importance of research on the Indian health
system.
Basic operations research techniques for NGOs
.
Research and ethics specially in the area of women's reproductive health
■
-
Organizational Management & Development
• Transparency and accountability in how
h?” funding is spent for health care service
delivery efforts
(e.g. fund-raising, advocacy, systems
■ Strengthen capacity of local NGOs*
cXtin^onstructive dialogue for effective program development and delivery
.
between NGOs and their constituencies
• •
!
Il
^7^
Networking & Partnership Development
. Kev issues affecting the ability of NGOs, businesses and government to partner
- Creation of an understanding of different perspectives NGOs, medical profession.
Business and government have towards health service delivery and developing an
environment for working together
- Role of NGOs, business, and government in addressing environmental pollutants
(air, water, food, occupational health)
.
.
Mechanisms such as local, regional conferences for bringing professionals of
-
■
diverse backgrounds together
Extending support to peoples'initiatives like the .ISA
Creation of an understanding of different perspectives NGOs, medical profession,
business and government have towards health service delivery and developing an
environment for working together. We feel that the scientific commumty too
should be included in any such partnershi p/s.
Collective action
Collaboration
Advocacx
Partnership
Partnerships between NGO, private and public health care
Explore the principles on which partnerships between various stakeholders
(especially corporates ) can evolve in the domain of primary health
Identification of key regional health issues
•
What we would need to do to promote South-South Collaboration
■
■
■
■
■
•
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■
.
Miscellaneous
■ Creating access to health information
V^■ Creating access to health information using internet technology
■ Effective steps (Clarification requested)
■ Health Infrastructure Development - Blood Banks, Paramedical
■
ambulances, etc.
War and its consequences on health of the poor
start,
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Department of Community Health Sciences
The Aga Khan University
, Karachi, Pakistan.
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RTP
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Regional Training Program
I
introduction
*
In Pakistan, as in other developing countries, managers and mid-level pro- *
*
fessionals engaged in health and social sectors, are faced with complex administrative, organizational, and program implementation and evaluation *
issues. Unfortunately, there are few community-oriented, problem-focused *
x and pragmatic training programs that can provide them with the conceptual J
J knowledge as well as practical skills and expertise to effectively address
★ these complex issues. Developing such a comprehensive, practical and ★
J cost-effective training program had been identified as a critical need for all *
I the member countries of The Aga Khan Development Network Program J
< (RNP, 1993).
>
*
*
T The Regional Training Program (RTP) is a response by the Department of *
* Community Health Sciences (CHS) of the Aga Khan University (AKU) to
this critical need of Pakistan and other countries in the region. The RTP is
v being conducted regularly since 1995.
*
i'
♦
*
★
Goal
*
The overall goal of the Regional Training Program is to further strengthen *
T the professional expertise and problem-solving skills of front-line health and *
J development related managers so that they can provide more efficient and J
effective health and development programs for their communities.
*
*
* J Target Audience
I
The RTP is particularly useful for mid-level health and development
# * workers, managers, researchers and planners working with different levels *
* of government, NGOs, and international agencies.
*
*
•y It is designed to benefit the participants, their parent organizations, pro- ♦
J grams and the target populations they serve. Over the years, RTP drew
participants from members countries of the Aga Khan Regional Net
work Program (i.e. Pakistan, India, Bangladesh, Kenya and Tanzania),
government agencies, and other NGOs working in Pakistan and in neigh
boring countries (e.g. Afghanistan and Tajikistan).
Program Components
The Regional Training Program offers four “types” of training courses:
1. Epidemiology, Biostatistics, and Surveillance
2. Health Systems Research and Management
3. Community-Based Social Development
4. Primary Health Care
All courses are offered at different times throughout the year by the De
partment of CHS of the Aga Khan University, Karachi. The program
also responds to individual organizational needs and produces tailormade courses for specific group of participants.
| Epidemiology, Biostatistics and Surveillance j
This course is designed to enable health professional to develop a scientifi
cally sound, and practical approach for identification and solution of chal
lenging field health problems.
Goals
This training aims to provide participants the practical skills in Epidemiology> Biostatistics, Surveillance and Information System Management to
better understand, assess and critically analyze the disease burden among
the populations they serve.
Objectives
By the end of the course, the participants would be able to:
> Understand and apply the basic principles of Epidemiology and Biosta
tistics.
> Design a feasible and valid study to address an important health issue in
their programs.
Content
I Epidemiology Sessions:
> Community Diagnosis: Person, Place and Time
> Incidence and Prevalence
> Questionnaire Design and its administration
> Sampling Methods
> Measures of Fertility and Mortality
> Epidemiological Basis of Fertility Control
> Screening Tests: Sensitivity and Specificity
> Study Design 1: Qualitative Studies
> Study Design II: Case series, correlation and Cross-sectional Studies
> Study Design III: Experimental and Cohort Studies
> Study Design IV: Case control studies.
> Measures of Association
> Bias, Chance and Confounding
> Causal Inference
> Sample size I & II
> Investigation of an Epidemic
> Surveillance
II Biostatistics Sessions:
> Introduction of population, samples, measures, variables, types of
measurements and the objectives of Biostatistics
> Organizing and displaying data
> Summarizing data includes measures of central tendency & variability7
> Applications of Mean and Standard Deviation
> Normal Probability Distribution
> Estimation of population means: Point estimation & confidence inter
vals
> Basic elements of Testing Hypothesis
> Type I and type II errors and power of the test
> Sample size determination in testing hypothesis
> T-test (two independent samples) and paired T-test
> Inference regarding proportions: One sample & two independent
samples
> The Chi-square test and contingency tables
> McNemar’s test
Project Development
This part of the course provides an opportunity to each participant to
practically apply concepts and skills learned towards addressing an identi
fied research issue related to their work.
Pre-course Task
Participants are required to identify the project topic and prepare in ad
vance the background information that can be utilized while designing
individual projects.
Medium of Instruction
English is the exclusive language of instruction. Participants should be
able to speak and write in English.
Participants’ Evaluation
The participants’ learning is evaluated through marks obtained in multi
ple choice questions (pre- and post-tests) at the beginning and end of the
course as well as on the basis of project assignment.
Educational Strategies
The basic educational strategy will be ‘‘Learning By Doing”. This will be
accomplished through lectures, tutorials, field survey and project devel
opment.
Duration of the Course
The course takes 23 working days. For the Year 2000, this course is
schedule from August 22 - September 21.
| Health Systems Researc
This course is designed to provide basic conceptual and technical skills in
undertaking Health Systems Research and using the knowledge gener
ated for program/interventions development and policy decisions lead
ing towards improved Health Systems Management.
It addresses some of the critical management problems that require im
mediate attention such as lack of planning and proper implementation of
health plans, lack of appropriate organizational structure, inefficient
management of resources, and lack of quality information for decision
making. Special emphasis is given to the application of management
skills for implementing primary health care.
Goals
The Health Systems Research and Management (HSRM) training program
is aimed at strengthening the professional expertise and organizational/
managerial skills of participants in Health Systems Research and Manage
ment.
Objectives
By the end of the course, the participants would be able to:
> Develop leadership capacity and effective team-work skills.
> Demonstrate knowledge of core concepts, strategies and issues of
Health Systems Research and Management.
> Conduct Health Systems Research and use research results for better
decision-making.
> Utilize existing resources within their health programs more effectively
and efficiently.
> Monitor and evaluate health care programs.
> Apply management skills for implementation of primary health care.
Content
> Systems Approach to Health Care
> Primary Health Care
> Strategic Planning and Human Resource Management
> Management Information System
> Quality Control
> Financial Management
> Health Systems Research
> Program Development, Monitoring and Evaluation
> Leadership Skills
> Institutional Management
Project Development
This part of the course provides a practical opportunity’ to each participant
to apply concepts and skills learned towards addressing an identified re
search and/or management issue related to their work setting.
Pre-course Task
Participants are required to identify the project topic and prepare in advance
the background information that can be utilized while designing individual
projects.
Structure
HSRM is a full time course lasting three weeks. It is conducted in English
and instruction is provided mainly by the faculty of the Department of
Community Health Sciences at the Aga Khan University. Participants bring
with them a breadth of experience in projects from different countries and
learning is encouraged through a mutual sharing of experiences. Pre- and
post-course tests are conducted to evaluate the performance of the instruc
tors and the value of the program to its participants.
Teaching Methods
A highly participatory method of teaching and learning is followed which
includes interactive lectures, large and small group discussions and group
presentations. Case studies are used to better understand practical prob
lems of healthcare research and management. Video presentations and field
visits are also offered.
Duration of the Course
The course takes 17 working days (Approximately eight hours a day, and
five days a week). For the Year 2000, this course is schedule from
June 6 - 28.
ment
Tliis course is designed to explore the interrelationships between self aware
ness, leadership skills, effective communication strategies, community mobili
zation, and health and social development.
Goals
lliis training course is aimed to provide an understanding of the social de
terminants of health and development and the importance of participatory
methods in community mobilization and empowerment.
Objectives
By the end of the course, the participants would be able to:
> Understand the essential concepts and dynamics of social change.
> Understand the essential features of participatory methodology, and its
applications for facilitating social change.
> Become aware of the relevance of self-development and importance of
communication skills for community development.
> Become aware of the type of management and research strategies ap
propriate for community development intervention
Content
> Introduction to Development and Its Dimensions
> Self-awareness
> Pardcipatory Methodology
> Violence and It’s Victims
> Gender and Development
> Qualitative Research Methods and Participatory Action Research
> Human Rights
> Management and Social Development
> Community Mobilization and empowerment
Medium of Instruction
English is the exclusive language of instruction. Participants should be
able to speak and write in English. Some instructions may be conducted
in Urdu, if necessary.
Teaching Methods
The course will provide an interface between experiential learning and
use of critical thinking. Participatory tools for reflection, case-studies for
analysis, simulation-games and exercises will be used. Participants will be
required to verbalize; as well as write out their feelings, thoughts and
analysis. Other methods of learning will include small and large group
discussions and presentations, video presentations and field visits. At the
end of the course, each participant will be expected to give a presenta
tion on a project that they would undertake in their respective programs.
Duration of the Course
The course takes 24 working days (approximately eight hours a day, and
six days a week). For the Year 2000, this course is schedule from
January 17 - February 12.
Primary Health Care
Primary Health Care (PHC) has been globally accepted as an appropriate
strategy for universal coverage of health care on equitable basis, at an afford
able cost with full participation of the people. Simple technologies have re
sulted in substantial reduction of mortality and morbidity and increase in life
expectancy. The national government has a commitment to adopt PHC phi
losophy, concepts and contents as a part of health care system of the coun
try. To fulfill that commitment, there is a need to train and reorient
healthcare personnel about PHC as a strategy, for its effective and meaning
ful implementation.
Front-line health care provider is a very important cadre in any health care
;ystem, functioning at the grass root level. They are in direct contact with the
community and know their aspirations as well as their frustrations. They
have proved their worth and importance in the health system. There is a
need to orient them with PHC, so that they may use their potential for the
improvement of health of the people in more effective way. They would
serve as an agent for change when equipped with necessary knowledge and
skills.
Goals
This course has been designed to orient front-line health care providers with
PHC philosophy, concepts and contents, so that they can function more
productively. They are already equipped with certain knowledge and hand
on experience, the aim is to build on what they already know, so that the
training program will complement their knowledge and skills.
Objectives
By the end of the course, the participants would be able to:
> Understand PHC as a concept and leam how to apply it in the field.
Describe PHC components, strategies and a its significance and appkeation.
> Improve skills related to the functioning as a front-line health care provider
in the field setting.
> Apply application of principles related to community, women, health and
development.
Contents
> Health and Development, and Health Care System
> Communication Skills
> Community Health
> Primary Health Care and Gender Issues
Community Health Management
> Reproductive Health
>
>
>
>
>
>
Management and Leadership
Maternal and Child Health (MCH) Services
Infectious Diseases
Environmental/Occupation Health
Community Participation and Its Importance for Health Care
Field-based training
Teaching Methods
Qualified and experienced faculty and staff of the department will conduct
the course. The basic learning strategy of the course is Learning by Doing,
with participatory approach. The class room sessions, group work and panel
discussions will be complemented with relevant field based exposure and
project development for experiential learning.
The whole course has been divided into eleven modules of two to five
day duration. Each new day will begin with a review of the previous
day’s work by one or two participants. Each module or a set of module
will be followed by a panel discussion, to provide an opportunity to the
participants to further clarify any of the concepts or contents with the
help of faculty and staff panelists. Different teaching material and hand
outs will be provided during the course for ready reference and prepara
tion of assignments. At the beginning of the course, a pre-test will be
conducted for all participants to find out areas needing further strength
ening. Similarly a post-test at the end will help in knowing improvement
in the learning achieved during the course.
Duration of the Course
The course takes 6 weeks. For the Year 2000, this course is schedule
from March 28 - May 07.
For more information about individual course contact:
Ms. Nadira Ashraf
Senior Administrative Officer,
Regional Training Program
Department of Community Health Sciences
The Aga Khan University
Stadium Road, PO Box 3500, Karachi 74800, Pakistan.
Tel: (92) 021-4930051 Ext. 4802/4835
Fax: (92) 021-4934294/4932095
E-mail: nadira.ashraf@aku.edu
)l.
VIII SATURDAY, NOVEMBER 19, 1994 DECCAN
HERALD
Community health
BANGALORE:
■ It is only when some epidemic strikes that
the role of community medicine comes to the
forefront. A voluntary agency called
Community Health Cell (CHC) has been doing
commendable job in the field of social
awareness towards the need for hygiene and
good health. A group of resource persons
moved beyond the Community Medicine
Department of a medical college in Bangalore
and started this body over a decade ago. The
group did a study-reflection-action
experimental project, which resulted in the
CHC.
The CHC is also involved in evolving
educational strategies that will enhance the
awareness on health issues. Promotion and
support for community health action through
collaboration between voluntary and
governmental efforts is another area of
initiative. It also intends to build a library and
documentation centre in community health.
The CHC consists of a small core group of
health professionals, research/training
assistants supported by a large informal
network of professional associates. Its scope
of interaction includes individuals as well as
voluntary agencies in the health sector. It also
networks women’s groups, environmental
groups and people’s science groups. It
provides information, guidance, training and
expertise to those in the field.
More details can be hadfrom CHC, No: 367,
Srinivasa Nilaya, Jakkasandra, Koramangala
I Main, 1 Block, Bangalore 560 034. © 5531518.
Simon Varghese
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Go rA H
The Mitanin Programme- the context, rationale and policy perspective.
Dr Alok Shukla,
Secretary,Government of Chhattsigarh,
Department of health and family welfare
’ The context:
Chhattisgarh is a new State carved out of Madhya Pradesh on 1st November 2000. It is
the 9th largest State in the country. It has a population of a little over 2 crores.
Chhattisgarh has 16 districts, 96 tehsils, 146 blocks, and approximately 9,129 village
Panchayats. It has about 19,720 villages, and 54,000 habitations. The State has 9
Municipal Corporations, and 66 other Municipal bodies.
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Chhattisgarh has relatively poor health infrastructure. It has only 9 District Hospitals.
Only 114 Blocks out of 146 have Community Health Centers. It has 786 Sectors and
3878 Sections. Large number of posts of doctors, and paramedical personnel are vacant.
Many PHCs in the remote tribal areas do not have doctors.
1
U,
Chhattisgarh has approximately 34% Scheduled Tribe population, 12% Scheduled Caste
population, and more than 50% Other Backward Classes. People are relatively poor. The
State is rich in natural resources. It has large reserves of coal, and iron ore. It also has a
lot of lime stone and Bauxite. Recently Diamond has been found in Chhattisgarh.
Chhattisgarh has approximately 40% forest cover. The Literacy levels of Chhattisgarh
are quite high. Health Statistics are on the other hand, still poor. Some important figures
from the 2001 Census are given below: Chhattisgarh
Indicator
India
Population________
Decadal Growth Rate
Sex Ratio_________
Literacy Rate
102.70
21.34
933
65.38
2.07
18.06
990
65.18
Female Literacy Rate
54.16
52.40
Some other important Health Indicators are given below: -
CHHATTISGARH
Population____________________________
98.13 ____________ 2.06
HDI__________________________________
45______________ 39
Sex Ratio (1991)_______________________
927 _____________ 985
25.4 ____________ 26.3
Crude Birth Rate (SRS 2003)____________
Crude Death Rate (SRS 2003)___________ ______8.4 _____________ 8.8
Total Fertility Rate (1997)_______________ ______3.3 _____________ 3.6
I MR (SRS 2003)_______________________
66
76
Couple Protection Rate by Sterilization %)
29.5
30.2
INDICATOR__________________________ INDIA
Adult Literacy Rate (age 15-34)__________
Total_________________________________
Male_________________________________
Female_______________________________
Scheduled Caste Population (%) 1991_____
Scheduled Tribe Population (%) 1991_____
Urban Population (%)1991_______________
Percentage of Married Women in 15-19 age
group (1991)__________________________
Proportion of Women in Work Force (1991)
Proportion of Farm Labor in work force
(1991)________________________________
Houses with Electrification (%) 1991_______
Houses with Safe Drinking Water (%) 1991
Villages connected with mettle roads (%)
1991
7.95
25.7
46.62
64.13
29.14
12.2
32.46
17.4
35.3
22.3
41.89
40.99
26.1
42.4
62.3
23.06
31.67
51.1
36.90
20.84
56.86
69.56
43.48'
16.73'
2
Though we have progressed a lot in the field of health, yet we still have a long way to go.
Diseases like diarrhoea, malaria, leprosy, and tuberculosis still present a major health
problem in the State. Measles still causes death of children in the State. Our Infant
Mortality Rate is 76, which is very high in comparison to the developed States of the
country. Many women still die during pregnancy, and labor for-want or proper care.
Anaemia, and malnutrition are present in the State on a large scale.
The system of Public Health, which has developed in the last few decades, has been
constrained by an increasing distance between the people, and the health services.
Underlying this is the increasing complexity of the health system itself. The result of this
is that people are not able to benefit fully from these public health services. On the other
hand after being educated in the ultra-modem, mechanized, and urban environment,
doctors are not interested in working in rural areas.’As a result of this today there is a
great shortage of trained doctors, and health workers in rural areas. On the other hand
incompletely educated quacks are taking advantage of the public in these areas. On the
one hand the Health Department feels that people do not take advantage of the services
offered by the Government and on the other hand people feel that Government is not able
to provide even basic health care services to them. The reality lies somewhere in
between, and there is gap both on the supply side as well as on the demand side. Present
policies have instead of empowering people, increased their dependence on the
Government machinery. Our present system is wholly hospital based. In this system,
treatment of diseases has got precedence over prevention of diseases, and programmes of
improvement of Public Health. We must remember that all our policies should be made
keeping communities in focus, as empowerment of people is out ultimate goal.
Health infrastructure is very limited in Chhattisgarh. 10 of our 16 districts do not still
have a functioning district hospital though government sanctions for converting them to a
district hospital have now been accorded to all of them. There are 146 blocks in the State,
yet there are only 114 Community Health Centers. Most hospitals do not have modem
equipments. There are only two medical colleges in the State. Even the hospitals of these
medical colleges do not have adequate modem equipment. Health department gets a very
limited amount of money for medicines. Because our programmes are not focused on the
community, the poor do not get the desired benefit of even these limited resources.
Though programmes are made to benefit the people living below the poverty line, in
reality it is only the middle classes who are able to take advantage of them. The real poor
often times are not able to access government health facilities, and lose both money and
health at the hands of quacks.
Being a new State we have no infrastructure in many fields. There is no drug-testing
laboratory in Chhattisgarh. Medicines can therefore not be tested in the State. Similarly
there is no facility to test food adulteration in the State. There is no institute to train
health workers in the State. A good system to collect health statistics also does not exist
in the State. A good Information, Education, and Communication machinery is need to
ensure community participation in health. It is simply lacking in the State.
3
Needs of Primary Health
At present Health Services are focused on cure of diseases. Enough attention is not paid
to promotion of health, and prevention of diseases. Though a big system of Primary
Health, having Sub Health Centers, Primary Health Centers, and Community Health
Centers, has been created, during the last few years, yet this system is not able to work
according to expectations. It is necessary to improve this system. The following needs to
be done for this: -
1. Make a system of Public Health based on the community, in which people should
be able to solve their day-to-day health problems themselves with the help of
local doctors. The help of many Non-govemment organizations existing in the
state and the Private Sector should be taken for this.
2. In order to empower communities for Public Health it is necessary to develop an
understanding of Public Health among the social workers, and communities, and
develop capacity to solve ordinary health problems at local level. Training of
voluntary workers, and people working in social sectors will have to be organized
for this. This will have to be done on a large scale, and the efforts of voluntary
workers will have to be integrated with governmental efforts.
A good referral system will have to be developed for such decentralization of
Health services, so that people know clearly where they have to go for solution of
problems, which they cannot solve at local levels.
4. Full assistance of Local Government institutions should be taken for the
decentralization of Health Services. There is a very developed and capable system
of Panchayati Raj institutions and Urban Local Bodies in Chhattisgarh. These
institutions have been given full responsibility for Public Health by law. It is
necessary that these institutions are trained to make their full use in the health
sector, and adequate powers are delegated to them.
5. While planning for expansion of health services it is necessary to keep in mind the
rights of the disadvantages classes. Many studies have shown that the poor are not
able to take advantage of the schemes, which the government has made for the
poor. Therefore we must ensure during the planning process itself that the benefits
of the scheme go to the target group. New strategies, making use of the private
sector will have to be examined for this.
6. Our programmes should help innovations, and provide full opportunities to new
ideas.
7. Training of people working in the government system will also be necessary, so
that they are able to work in partnership with Local Government institutions,
Non-govemment organizations, and Private sector for empowerment of people to
benefit the disadvantaged classes.
8. There is a big challenge to bring the doctors of Indian Systems of Medicine, and
other systems of Medicine in the mainstream of Public Health. People in villages
often times have great faith on these systems of Medicine. These systems of
4
Medicine have sufficient human resources too. It is necessary to plan for their
maximum development, and maximum use in Public Health.
"Mitanin":. The Community Health Worker Scheme
It is a generally accepted fact that improvements in Primary Health can be made only
through the involvement of communities in the delivery of health services. However
different people mean different things when they talk of community participation. Some
of these different meanings are described below: 1. To some persons the meaning of community participation is wholehearted
acceptance of Government schemes by the people. They feel Government knows
what is best for the people, and therefore makes the policies and programmes,
which are best suited for their good. If people do not benefit from such
programmes it is their own fault, as they do not participate fully in Government
schemes.
2. Some people feel that community participation means demand generation for the
services provided by the Government. If this view is accepted it will mean that
though all services are readily available to the people, they do not make use of
these services, as they do not know what is good for them. Government should
therefore launch Information, Education, and Communication (IEC) programmes,
so that people understand the importance of using the services. According to this
view also the blame rests squarely at the people for not using services.
3. Still other people feel that the community can participate in Government
programmes in service delivery as well. These people acknowledge that the
service delivery mechanism of the Government may not be foolproof, and
therefore people may not have access to services. They thus feel that Community
can help the Government in service delivery. The concept of depot holders of
simple medicines, and contraceptives is such a concept. Most planners in
Government now realize that the outreach of Government staff is limited. They
also accept that increase in the numbers of Government employees to increase the
outreach to all the habitations is not cost effective. The decision of the Planning
Commission of India to freeze the number of Sub-Health-Centers at the 1991
population level is the result of such realization and a very real resource crunch.
Still these people do not really accept the ability of communities to plan and work
for their own good. They do not believe in the "Empowerment Approach"
4. There is a very small group of people who has faith in the ability and the power o
the communities to shape their own destiny. This group of people feels that
community participation should mean empowering the community to plan and
work for their development. They feel that Government should help the
community in making their own village health plan, and implement it. This should
however not become an excuse for withdrawal of the Government, but should the
lead to a more meaningful partnership between the Government and the
Community. "Right to Health" is an inalienable right of the people, and it is the
duty of the Government not only to make all the services available to the people,
but also empower the communities so that they can demand, and get what is due
to them.
5
We are a firm believer in the Empowerment concept of people’s participation and are
committed to ensure this the field of Public Health. Government of Chhattisgarh has
launched the "Mitanin n scheme for this purpose. Mitan in Chhattisgarhi means a close
friend. Mitanin is a female friend.. In this scheme it is proposed that one woman will be
identified in each habitation in villages, and in each lane in cities, to work as the main
link person between the Government and the community. This person will be a friend of
the community, and will therefore be known as the "Mitanin
This scheme involves some guarantees to the community from the Government, and
some responsibilities, to be taken by the Community, and Panchayati Raj Institutions.
These responsibilities are described below.
1. Responsibilities of the Community and Panchavat:
1.1. Publicity of the scheme in the communities.
1.2. Mobilizing the communities for Health.
1.3. Helping the communities to identify one "Mitanin" for each habitation.
The Mitanin can be any woman living in the habitation acceptable to the
community. It is not necessary that she should have formal education, but it will
be helpful if she knows how to read and write. She should be willing to devote her
time to activities relating to the health of the community.
1.4. Helping the community in deciding a compensation package for the Mitanin. The
Mitanin will be a volunteer, who will not get any honorarium or salary from the
Government. However she will need to be compensated for her time and efforts
by the community. No uniform compensation package is being suggested in the
scheme. The compensation package should be agreed between the community
and the Mitanin.
Some suggestions for the compensation package are: The community may pay the Mitanin directly a fixed amount, either in cash or
in kind (in the form of grain). This can be monthly or yearly. Payment to be
made in kind every year at harvest time.
The Panchayat may decide to pay the Mitanin something from their funds.
The community may decide to pay the Mitanin a certain amount either in
cash or kind for services rendered as user fee.
The Panchayat may decide to allocate five acres of land along with a
source of irrigation as "Mitanin land". This land will not be transferred in the
name of the Mitanin, but she or her family will be allowed to cultivate this
land and take the usufruct till she is working as the Mitanin of the habitation.
This is similar in concept to the "Kotwari land"
Cash contribution by each family to be paid to the ’’Mitanin" every
week/month/year or cash fee at predetermined rates for services to the
individual families.
Any other method of compensation, which the community and the "Mitanin"
agree upon.
6
One should attempt to get the agreement reached between the "Mitanin" and the
community of the habitation to be in writing. The scheme recognizes that this is a
difficult process and may be possible to initiate only after at least one year of the
programme has passed and its utility is visible to the community. If she regularly
gets the drug supply and the slides she sends get reported in time and her referrals
gets honored, then the community would be much easier to convince for
supporting her.
1.5. Provide space in each habitation for health related activities, including
immunization, labor, storing of medicines, etc.
2. Guarantees bv the Government:
If the Community and the Panchayat fulfill their responsibilities, they can make an
application to the collector of the district for the Government to fulfill its guarantees,
and the Government will then guarantee the following: 2.1. Government will train the Mitanin identified by the community and‘the
Panchayat.
2.2. Government will give refresher training to the Mitanin as often as is necessary,
and till such time as the Mitanin is fully competent to do her job well.
2.3. Government will integrate the Mitanin in the Government Health delivery
system.
2.4. Government will provide all the free medicines, other materials, and services to
the community through the Mitanin.
2.5. Government will provide an essential equipment and medicine kit to the Mitanin
for Maternal and Child Health, Reproductive Health, Family Planning, safe
drinking water, sanitation and epidemic control.
There are 54,000 habitations in approximately 20,000 villages, and 10,000 village
Panchayats of Chhattisgarh. Ideally, when the scheme is fully implemented, we hope to
have a trained Mitanin in each of these 54,000 habitations, and also in every lane of the
slum areas of the cities. Thus we are aiming at training approximately 60,000 Mitanins. It
is hoped that these trained Mitanins will be the cutting edge of actual delivery of all
Primary Health related services to the community. They will work in close coordination
with and under the supervision of the ANM. They will be compensated for their services
not by the Government but by the community.
In order to implement the scheme the following steps were taken: 1. Action Aid India was identified as a strategic partner NGO for the scheme, and the
State Government entered into an agreement with Action Aid India for this purpose.
2. A dedicated core team of professionals was developed at the State level for the
implementation of this scheme. This team is called the State Health Resource Center
(SHRC). The personnel for this core team have been drawn from NGOs working in
the field of Health from all over the country.
3. Training modules for the Mitanin were developed. The modules are in many parts.
There is an inception training, which is given to every newly recruited Mitanin, and
then other training capsules, which are administered at the Primary health center or
7
training institutions at regular intervals, as the Mitanin starts her work. The training
module is in Hindi, and has been made keeping in mind that the trainee is a neo
literate. The module has lots of practical exercises, and field work. Difficult concepts
should are explained with examples from the local environment. The training has a
provision of being run at the pace of the learner, and takes into consideration different
learning styles, and different learning capacity of different people. The training
module has detailed and clear cut instructions for the trainers. Good quality and
appropriate teaching-learning material is being developed.
4. Development of a training package of training of trainers (TOT).
5. Training of trainers.
6. Publicity of the scheme, and training of Panchayati Raj representatives.
7. Community Mobilization.
8. Identification of Mitanins. More than 20000 Mitanins have already been identified,
and have undergone the first phase of training.
9. The continuing training of the Mitanin and her integration with the Health Delivery
System is an ongoing activity in all the Mitanin blocks.
10. Certain activities which are important for the programme include Training of PHC
doctors and training of MPW (M) and ANM. These activities should be started soon.
Role of "Mitanin”
"Mitanin” in Chhattisgarhi means a friend. In fact She is much more than a friend. It is an
age old tradition in the villages of Chhattisgarh, that people make other people their
"Mitan" or ’'Mitanin". It is customary in the villages of Chhattisgarh for girls to become
Mitanin of their close girl friends. This is done ceremoniously. Once the two girls have
become Mitanins, they are closer to each other than real sisters. This relationship
continues for the rest of their life, even after they are married, and becomes a bond
between families The "Mitan" or the "Mitanin" is a friend not only in this life, but even in
heaven. The friendship continues even after marriage, and becomes a bond between
families. The "Mitans" and "Mitanins" are ready to sacrifice everything for each other. It
is this tradition that the scheme seeks to revive. The "Mitanin" therefore is not just a
voluntary worker, but will be a friend, philosopher and guide for the community of the
habitation. The community of the habitation should have full faith and confidence in the
"Mitanin" and they should have a rewarding, friendly relationship, which may also have a
sentimental element. In this sense the "Mitanin" will be a true guide to the community of
the habitation in all their endeavors. In the field of Public Health the "Mitanin" will have
the following functions: -
1. She will give health education to the community of the habitation.
2. She will take on the leadership role in all Public Health activities of the village,
and will encourage community service for public health specially in a. Cleanliness of the village.
b. Ensuring safety of drinking water.
c. Making a parapet wall on all wells and covering all wells.
d. Making soak pits and proper drainage system in villages.
e. Teaching proper drinking water storage practices to the people.
8
3.
4.
5.
6.
f. Encouraging people to make and use sanitary latrines.
g. Taking care of the health of women and children specially promoting good
health practices by i. Teaching good nutrition practices.
ii. Teaching good breast feeding and weaning practices.
iii. Taking care of iron and iodine deficiency by propagating the use of
iron folic acid pills, and iodized salt.
iv. Propagating the use of iron and Vitamin A rich foods, and giving
supplementary Vitamin A to children.
V. Ensure regular weighing of children to monitor growth and
development.
vi. Ensure at least 3 Ante natal checkups for all pregnant women.
vii. Ensure that all deliveries are institutional deliveries.
viii. Ensure 100% registration of births, death, marriages, and
pregnancies.
ix. Provide consultation on MTP services.
x. Provide consultation on Family Planning sendees, and ensure
regular supplies of contraceptives.
xi. Help women in reproductive health.
xii. Provide counseling to youth on matter related to adolescence,
puberty and sexuality, with special reference to STD, and HIV
AIDS.
xiii. Important health education inputs on diseases like Malaria,
Leprosy, Tuberculosis, Diarrhoea and Dysentery.
xiv. Be a link between the Government Health system, and the
community for all National Health Programmes.
xv. Provide Health Education for other important things.
She will provide first aid, and over the counter (OTC) drugs for minor ailments.
She will be trained in taking care of common illnesses in the village, and will
gradually take on the responsibility for treating these diseases in the village. This
will be done gradually during the refresher training organized every fortnight in
the sector hospitals. The emphasis in these trainings will be on skill development.
The "Mitanin" will be allowed to treat diseases only when she has attained the
required proficiency levels in both knowledge and skills. She will be examined
periodically, and given certificates of proficiency. The important thing in deciding
whether she should be allowed to treat a disease is the confidence, which she has
in her own ability, and the confidence, which the sector health team has in her
ability. A detailed system of examination, and certification will be worked out.
She will be given the knowledge to refer all cases beyond her competence to the
proper place where they can receive proper health care.
Relationship with the ANM and other Health Staff: - The ANM and other
health staff will look at her as the most important asset in the habitation through
which they can reach out to the community. The "Mitanin” will look at the ANM
as her chief source of knowledge and strength. The two will not be competitors
but will complement each other. Essentially the interrelationship of the "Mitanin"
9
and the ANM or other sector health staff will be positive fulfilling, rewarding,
friendly and supportive.
a. The ANM will do the following for the "Mitanin" i. Train the "Mitanin" in the fortnightly refresher training courses.
ii. Teach skills to her by making her do things under supervision.
iii. Conduct examinations at frequent intervals for certification.
iv. Be the main link between the "Mitanin" and the health system.
v. Provide support to her in all difficult situations.
vi. Build confidence of the "Mitanin" in taking care of the village
community.
vii. Be the chief spokesperson of all the "Mitanins" in her area to the
government system.
viii. Ensure supplies of health education material, essential drugs,
record keeping material, contraceptives, etc.
ix. Counsel the "Mitanin" in her work specially in unforeseen
situations.
X. Provide legitimacy to the health related work of the "Mitanin" in
the community.
xi. Help the "Mitanin" in all referrals.
b. The ’’Mitanin” will do the following for the ANM i. Provide support to her in the community of the habitation for all
Public Health work.
ii. Provide her basic data about the community of the habitation.
iii. Help her in the registration of marriages, pregnancies, births and
deaths.
iv. Determine the contraceptive preferences of the community and
help the ANM in the CNAA strategy of family planning.
v. Be the main source of information about the community of the
habitation.
vi. Create an environment in favor of positive health in the
community.
vii. Help the ANM in staying in the village, and organizing camps and
other health related activities.
viii. Provide legitimacy to the Public Health work of the ANM in the
community.
ix. Help the ANM in surveillance of important diseases.
x. Help the ANM in organizing relief, and in the prevention of
epidemics.
xi. Help the ANM in all health related campaigns.
7. Relationship with PRIs - "Mitanins" will work in close association with PRIs.
The selection of "Mitanins", and the agreement between the "Mitannin" and the
community of the habitation will be approved by the Gram Sabha". Public Health
is an important function of PRIs under the 73rd Constitution amendment. At
present the PRIs do not have any mechanism of performing this important
function. With the introduction of the "Mitanin" scheme the PRIs will be able to
discharge their duties easily. Civil society, and a free press are important pillars of
10
a democracy. These two do not really exist in a village. The "Mitanin" can
perform the functions of both "organized civil society", and a "free press" in a
village to provide succor to and sustain democracy at the Village Panchayat level.
She will be in constant dialogue with the people of the village on all important
issues, and therefore she is competent to be the voice of the civil society.
Similarly she will the main source of transmitting information about development
schemes, and work of the Panchayat, and government- to the people. In this
manner she is similar to the free press.
a. Panchayats will do the following for the ’’Mitanin” i. Gram Sabha will approve the selection of "Mitanin", and also the
agreement between the "Mitanin" and the community of the
habitation.
ii. Panchayats will ensure that the community of the habitation
honour their side of the agreement.
iii. Panchayats may decide to pay the "Mitanin" something for the
services they render.
iv. Panchayats will help in the irrigation of the "Mitanin land" if
provided by the community of the habitation or the collector.
v. Panchayats will monitor the work of the "Mitanin", and if they find
that the "Mitanin" has not performed her duties well, the Panchayat
may remove her, and ask the community of the habitation to select
a new "Mitanin".
vi. Panchayats will ensure that the "Mitanins" get good training, and
get regular supplies of publicity material, contraceptives, essential
drugs, and other things.
vii. Panchayats may use the "Mitanin" in the implementation and
monitoring of other welfare, and community empowerment
schemes.
b. ” Mitanin” will do the following for PRIs i. She will send regular reports to the Panchayat about the health
status of the community.
ii. She will attend meetings of the Panchayat whenever she is asked to
do so by the Panchayat, and will give all information about the
health status of the habitation, which is necessary for the
Panchayat to make informed decisions about the programmes, and
schemes being run in the habitation.
iii. She will help the Panchayat to implement, and monitor such other
welfare schemes, and community empowerment schemes, as the
Panchayat may require her to.
iv. She will follow all lawful instructions of the Panchayats.
8. The "Mitanin" will gradually take on such other responsibilities, and perform such
other functions as the Panchayats and the district administration may decide. She
will be trained for performing these duties, and duly compensated for them by the
concerned departments.
11
The "Mitanin" will be the main link between the government and the people in a
habitation. It must be stated here that in order to derive full benefit of the scheme it will
be necessary that health department delegates full powers of programme planning, and
implementation to PRIs. Capacity building of PRIs will also be necessary.
Selection of "Mitanins"
"Mitanins" are to be selected by the community of the habitation. The selection has to be
formally approved by the "Gram Sabha". However, just a formal approval of the Gram
Sabha without involving the community will defeat the very purpose for which the
"Mitanin" scheme has been conceived. The selection process described below is to ensure
that the community actually decided who the "Mitanin" will be, and the process of
community does not remain on paper. It is therefore important that the process is
followed in letter and spirit.
The selection process follows the following steps: -
1. A series of workshops and sensitization meetings were held at the state level and
district level to orient the representatives of PRIs and key officials and convince
them about the scheme. PRI representatives not only understood the full import of
the scheme, but are also committed to its success.
2. A team of facilitators was then selected and trained to sensitize the community in
each habitation, and help the community in the selection of the "Mitanin". One
team of facilitators was trained for each block. It was ensured that facilitators
know the local language well, understand the local culture, have positive social
attitudes, and faith in the inherent strength of communities, are good
communicators, know how to work with groups and are willing to live in villages
with the villagers, and make night halts in villages. Some examples of persons
selected as facilitators are: i. CDPO or Supervisor of ICDS.
ii. ANMorLHV.
iii. Village level workers of various government departments.
iv. Panches.
v. Members of Didi Banks (Credit and thrift groups of women)
vi. Members of Zila Saksharta Samitis.
vii. Members of Watershed committees or JFM comittees.
viii. NGO workers.
3. The facilitator then visited the selected habitation as many times as necessary.
Often they made night halts in the habitation. They spent time with the
community, so that the community feels that they have become one with them,
and freely share their joys and concerns. This is a rather prolonged process, and
should not be hastened.
4. Once the facilitator has the confidence of the village community, the subject of
the "Mitanin" scheme is discussed with them. The concept is explained in detail.
The facilitator then discusses the possible choices, and the pros and cons of
choosing various prospective women as "Mitanins" These discussions are held in
12
an informal environment. The facilitator tries to develop consensus amongst the
members of the community on the choice of the "Mitanin”. The facilitator also
discusses with the prospective "Mitanins” the things, which the job entails, and
the responsibilities, which they will have to undertake.
5. Once the facilitator is convinced that a consensus is emerging on the choice of
"Mitanin”, the facilitator calls a meeting of the community of the habitation to
make a formal choice. In this meeting the voluntary nature of this work and the
possible different ways of the community compensating the "Mitanin" for her
services are also discussed freely.
6. A number of village level activities, which are mobilisational in nature, are
carried out. Of this the use of the kalajatha for spreading the spirit of the
programme and enthusing the people to participate in this programme is one
major step. There can be other major publicity and mobilisational activities like
wall writings, posters, meetings, cultural events etc to build interest in the
programme.
7. Once this stage has been reached, a formal meeting of the Gram Sabha may be
called, and the agreement approved by the "Gram Sabha". The sarpanch of the
Panchayat will then endorse the agreement, and then send a request to the Block
programme team to train the "Mitanin"
Training of "Mitanins"
After a "Mitanin" is selected, and a formal agreement is signed between the "Mitanin"
and the community of the habitation, and approved by the Gram Sabha, the Village
Panchayat endorses the selection and in effect sends a request to the Block Medical
Officer to train the "Mitanin". All the expenditure on the training is borne by the
Government. "Mitanins" are provided training in many stages. First stage of the training,
itself made of six rounds is institutional. The second stage of the training will be a series
of refresher trainings organized at regular intervals at the panchayat or cluster level or
PHC through suitable training institutions and training arragnements.
First Stage : Institutional Training: - This training will include the following: 1. Attitudes: - The training is designed to bring in positive attitudes in the "Mitanin”
about the power of people, empowerment of women, the strength of community
work etc.
2. Knowledge: - She is given knowledge about basic concepts in Public Health,
various Government schemes, and programmes, National Health Programmes,
Signs and Symptoms of common diseases, etc.
3. Skills: - Skills relating to communication, management, group behavior etc. will
be developed during the course of the training. Skills relating to disease treatment
are also developed.
The "Mitanins" are trained through a participative process of group work, field visits and
studies, visiting areas where community health volunteer scheme has been successful,
13
practical demonstrations, and field exercises. After each round of training they are
deployed and supported in a set of activities at the village level. The first two rounds are
on health rights and knowledge of available public health services and on child health.
The third round is on women’s health. The fourth round is on control of communicable
disease and the fifth and sixth rounds are on first contact curative care. At the end of an
year they would also have a training on village level health planning.
Second Stage : Refresher TrainingH : - Refresher training are organized monthly at the
sector PHC/ cluster level. This training will concentrate on reinforcing what was learnt in
the first stage plus further practical aspects of diagnosis and treatment of common
illnesses and a lot of troubleshooting and on the job training. It will aim at skill
development and practice so that the ’’Mitanin” gradually develops confidence and is able
to take care of the health needs of the community. This training will need to go on
indefinitely- it is a continuous process.
The specific skills she would be trained in include: Making of peripheral blood smears.
Detection of anemia.
Antenatal care.
Weighing of children.
Recognizing malnutrition and being able to counsel the family on integrated
management of childhood illness with a focus on malnutrition.
6. Recognizing Acute Respiratory Infections, and giving specific drug from her kit
when required.
7. Recognizing fever, and giving choloroquine presumptively.
8. Recognizing when a patient should be referred to a hospital.
9. Recognizing signs of dehydration, and administration of ORT.
10. Conducting local level health education meetings for specific groups.
1.
2.
3.
4.
5.
The Sector/cluster training team will make an assessment of the knowledge and skills of
the "Mitanin" from time to time, through an assessment system,on the basis of which she
will be provided refresher training and allowed to take on more of the responsibility of
health care of the community gradually.
In conclusion:
This chapter only outlines the basic concept of the 'Indira Swasthya Mitanin" Scheme,
and the broad contours and outlines of its implementation. The remaining chapters of this
book will describe the processes in far greater detail. It needs to be stated that the scheme
is in its infancy yet, and therefore it is premature to assess the impact of the scheme on
Public Health. It must however also be mentioned that the scheme has evoked great
enthusiasm in all the villages, and peoples’ participation is very visible for all to see.
14
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