COMMUNITY HEALTH...., PROJECT PROPOSAL JANUARY 1984 - JUNE 1986.pdf
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Report
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Community
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January
1984
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Bangalore.
June
1986.
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PROJECT PROPOSAL
Centre
for
Non-formal
&
Continuing
Education
' ashirvad *
30 st marks road
L-7'
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Bangalore 560 001
by
CHC - I
Not for Quotation
For Information
Purposes Only
HEALTH
COMMUNITY
for an alternative process
the search
i
-
I
Report
of
a
study
reflection
action
Community
Health
Cell,
Bangalore.
January
1984
June
1986.
Centre
for
Non-formal
&
Continuing
experiment
Education
' ashirvad '
30 st marks road
Bangalore 560 001
by
C H C
For information only
I
Not to be quoted
t
Report of the Community Health Cell
January 1984
-
June 1986.
The Process
1*1- Evolving guidelines forthe experiment
1.2 Involvement with mfc at National level
14
1.3
Catalyst role
1.4
Wise Counsel
2.
The Initiatives
Reflections on a new vision in. Health Care (CHAI)
2.1
2.2
2.3
2.4
Workshop on Medical Education and small rural
hospitals.
Workshop on Community Health (FEVORD)
Consultative Committee of Rural Development
2.6
Reflections on Community Health
Workshop on a ’People Oriented Drug Policy'
2.7
Reflections on dimensions of Community Health
2.8
Miscellaneous meetings
2.5
2.9 mfc organisational work
2.10 Bhopal intervention
2.11 Environmental Collective-Post-Bhopal
2.12 Drug policy issues.and rational therapeutics
2.13 Womens health issues
2.14 Support to Research Studies
2.15 UNICEF Consultancy
f
2.16 Miscellaneous events.
2.17 Interactions with individuals
2.18 Team development
2.19 Community Health - a collective perspective
2.20 Review and Evaluation
(CHAI)
1
3.
Some.thoughts on the future
3.1
Critical questions
3.2
A documentation cell
3.3
3.5
3.6
A communication and continuing education cell
An Action research cell
Networking
Summary of Needs
4.
Towards an Action Research Cell
4.1
Features of the cell including type of research,
team structure, funding and base.
3.4
5.
5.1
5.2
►
*
In Conclusion
Publication of the C H C Report
Phase II of the'process
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REPORT OF THE COMMUNITY HEALTH CELL 2s
JANUARY 1984 TO JUNE 1986
1.
THE PROCESS
The Community Health Cell was an informal study-reflect—
ion-action experiment, embarked upon by a small team in
January 1984.and a continuation of a process that had
begun some years ago.
The main objective was to gradually interact with all the
groups involved in Community Health Action in Karnataka
including individuals/ health project teams, networks,
coordination groups, documentation and education efforts,
training centres and build up an overview of Community
Health as a process.
As health practice researchers
committed, to a Community and epidemiological' orientat
ion, we hoped to study the situation by taking a macro
level overview of what was either a series of micro
level experiences of social reality, or ideologically
confined perspectives emerging through some networking
efforts. By so doing, we hoped, to actively participate
in what we had perceived from our earlier experiences,
to be a meaningful and evolving process in the country
since the seventies.
1,1
Evolving Guidelines for the experiment
Our efforts were tentative and cautious.
We were keen
to remain small and uninstitutionalised; so, we managed
to get support for our team of four to function from an
informal Cell in Koramangala for an initial period for
two years.
2
)
2
A small team, we felt, would have adequate flexibility to
relate to such a process. It would also allow us to ex
periment with more democratic participatory, non—Hierar
chical functioning, in keeping with our own ’health’
obj ective.
We decided to limit our main focus of efforts to Karnataka,
geographically, to allow for closer interactions with in
dividuals and groups with whom our work would bring us
in-fe contact.
Even Karnataka proved too large finally.
We decided not to structure our efforts too much.
Some
technical and overall operational guidelines were drawn up
and used as reference points in our interventions.
The guidelines as they evolved were
3o
We would meet and discuss any ideas for health
action with anyone who approached us;
b.
We would select those initiatives which we thought
had an element of social analysis and were open to
review/ reflection and work more closely with them;
c.
We would provide all of them with whatever supportive
information/documentation that we had access to;
d.
Often there were demands, to be resource persons in
initiatives that were mainly ad-hoc actions/events
within a project or institutional contex (eg) ad-hoc
camps, ad-hoc training programmes, ad-hoc celebration
of events. We generally referred them away to other
resource centres, since in our new order of priorities,
e.
we had to be selective.
We were open to association with any individual/group/
project or initiative which was keen to reflect and
analyse the existing health system and evolve more
►
meaningful approaches that were more relevant for the
poor and the under-privileged in society. Not-with
standing the divisions that exist - political, social
and, religious in developmental circles - in India
we adopted a more open-issue-based approach in keeping
with the perspectives of the medico-friend-circle of
which we were a part.
... 3
3
Another conviction frcm which
thi© approach was
our earlier experience that whatever the ideological
background the attitudes to health as a process,
among most groups involved with development in India,
is severely medical in its orientation# The DoctorDrug-Hospital model is a common fixed perception and
the awareness that health could be an _awareness
building process* an organisational_effortt_ a struggle
for health as a right, had yet to_ become _a__comm.on
f.
Since we were sensitive to the fact that health efforts
needed healthy team functioning we associated mostly
with groups who were more democratic and participatory
in their decision making processes and efforts. In
terms of larger meetings too, we participated in those
efforts that were sensitive to the idea of building
perspectives in a participatory way.
It mush be stated that in all our interactions we were not
neutral in our perspectives of health, We did encourage and
emphasise perceptions like sa.
health efforts going beyond medicalised, curative and
preventive efforts, beyond drugs, hospitals, dispensaries
and medical professionals.
b.
health problems and health efforts being seen in their
wider socio-economic-political, cultural and
ecological context.
c.
health as a process of awareness building and community
organisation and not merely institutional/project
building or provision of services.
4
4
d. health process/apprcaches to be evolved through greater
sharing^field experiences by activities and all those
involved including 'demystified* professionals and
sensitive academicians.
<
Only then would more socio
culturally relevant approaches emerge. This would then,
wean us away from the existing initiatives — transplants
of the Western model.
1.2 INVOLVEMENT WITH m.f.c. AT NATIONAL LEVEL
Very early in our planning efforts there was a request
by our m.f.c. colleagues, that our team, which was to
be based in Bangalore, should shoulder the organisational
responsibilities of the circle. This is a rotating
responsibility — a feature of the collective functioning
of the circle.
After some hesitation we agreed to this additional
responsibility, which included among other things, the
bringing out of a monthly bulletin and organising annual
and mid-annual discussion on health issues.
We decided
that in addition to our focussed efforts in Karnataka,
this added responsibility would give us an opportunity to
meet, communicate’ and interact with a wider group of people
all over India, searching for more relevant options in
health care.
1.3 CATALYST ROLE
We decided that our interventions would primarily be
that of a catalyst or animator.
We decided to actively
associate with ongoing meetings and dialogues organised
by other groups and resource centres, networking efforts/
training efforts and support individual initiatives as
well.
We did not call any meetings of our own nor
initiate a project of our own. The idea was to
understand the existing situation and to support
encourage ongoing initiatives without creating one
more centre, one more project.
5
I
5
1.4
WISE COUNSEL
A small nucleus of three senior persons were identified
with whom we regularly shared our plans and communicated
our ideas. They were not a governing council, but a
wise counsel, mainly listening, encouraging, raising
questions, sometimes confronting as we went along.
A network of associates/colleagues which included many
m.f.c. core group members, was a wider group with whom
we discussed issues/communicated and kept in touch with,
during these years.
2.
THE INITIATIVES
In the thirty months since we embarked on this experiment we were involved in many meetings, sharing sessions,
discussions, travels, field observations, reflections.
planning sessions and actions, To list these out
chronologically would serve only an administrative
purpose. We, however, ahare here a variety of inter
actions to give you a feel of the thought provoking
process we went through.
2.1
Reflections on a new vision of health and health care
and evolving of a strategy of reorienting/training
members of a hospital association towards this vision.
Apart from the initial reflection in May 1983 there
were concurrent and annual sessions where the evolving
process and training inputs were constantly
evaluated with the community health team of this
hospital association.
2.2
who had
Reflections with graduates of St John’s
participated in the rural placement scheme, During
these sessions we reflected on the relevance of
their work experience in small rural hospitals.
Problems of policies and practice in these
6
6
peripheral institutions were also identified.
It was
hoped, that the former would be relevant feedback to
the faculty of the college and the latter, feedbacK
to the coordinating hospital association, so that
collective reflections to identify solutions could
be initiated
2.3
Reflections with field level activists of a large number
of voluntary organisations from different parts of
Karnataka on the scope of Community Health. All of
them were members of a coordinating federation of
voluntary organisations.
Over the two years we also got opportunities to meet
individuals and team members from these projects
separately to discuss their perceptions of health.
2.4
A sequel to this, though not directly linked, was the
regular participation with many members of this
Federation., on a Consultative Committee on Rural
Development, formed by uhe Government of Karnataka,
to establish a dialogue between secretaries of Government
departments and representatives of non-governmental
voluntary agencies.
This idea was initiated by the
Planning Commission and this dialogue process is
evidently going to be greatly enhanced in the
Seventh Five Year Plan, period.
2.5
Reflections on "Community Health" with varied groups
such as s -
. i.
iii.
Participants of an Apprenticeship course
in ‘'development”;
Secretaries of state-level Voluntary
Health Associations;
Diocesan level Health Coordinators;
7
... 7
Members of training teams of Community Health
and Family Planning Department of a Coordinating
iv.
Church medical agency;
Vn
Participants of a course in community organisation
vi.
and development;
Members of a project evaluation team of a
■
coordinating agency;
Participants of a Regional Consultation organised
by coordinating health associations and social
vii.
service societies;
Formators of religious training institutions in
viii.
x.
Bangalore;
Teachers of a women’s college planning a social
awareness and sensitisation programme;
Participants of an intensive training in self-
xi.
renewal;
participants of a National Seminar for Youth
ix.
I
1
xii.
Leaders;
Participating youth leaders and youth groups
in a consultation on Youth and the struggle for
xiii.
justice and peace;
field officers of a funding agency;
Foreign medical students on an exchange programme.
xiv.
2.6
Workshop on evolving ’’A More People-oriented Drug
Policy” for members of a Hospital Association as part
of their annual convention in Bangalore. This
effort involved a series of reflections and group
discussions on drug policy and rational therapeutic
issues for s-
b.
a thirty member team of facilitators-doctors.
and health activists;
an audio-visual resource team, who produced a
c.
slide/cassette show on the theme;
a group of religious brothers, who wrote relevant
a.
liturgy on the theme;
8
8
d.
a street theatre group, who evolved a short skit
e.
on the theme;
background papers and a special issue of the journal
of the association on the theme apart from
participating in the entire proceedings of the
workshop;
f.
some short-term studies on use/misuse of drugs
in small hospitals and health centres.
It may seem surprising that so much effort should be
spent by a team interested in Community Health - on
the issue of drug policy and rational therapeutics.
It is our firm conviction that with the strangle-hold
that "drugs and prescribing" seem to have on the thought
processes of existing professionals and administration
of Medical Care institutions and even in the expect
ations of lay consumers - drug issues, can be levers
to confront and challenge the existing highly
medicalised system and stimulate social analysis and
some movement towards relevance.
2.7
i
A series of reflections on different components of
community health or associated dimensions in the
planning process.
a.
b.
Health Education
Governmental - non -governmental links in
c.
d.
health care
School as a focus of health action
Crisis in Medicine and the new vision of
e.
health care
Analysis of the existing health system
f.
Crisis in medicine and search for an
g.
h.
alternative process
Alternatives in Medical Education-
Community Diagnosis.
9
9
2.8
A few additional interactions (not possible to group
with the earlier categories) were sa. the colloquium on 'Health and Healing for all'
organised by St. John’s Medical College,Bangalore;
b.
A workshop on Training methodologies and awareness
building in programme for the Development of
Women and Children in rural areas organised by
c.
UNICEF and Government of Karnataka;
Evaluations and planning session organised by
the Centre for Nonformal and Continuing Education,
d.
Bangalore.
Mental Health course for community health team
eo
of CHAI and associates;
Refresher course in community health for Franciscan
f.
g.
Brothers Trained in Community Health;
Participatory evaluation of community health
projects organised by Indian Social Institute,
New Delhi.
Seminar on Research priorities in occupational
health organised by Regional Occupational Health
Centre, Bangalore;NIOH, Ahmedabad.and ICMR.
2.9
The medico-friend-circle organisational work, led to
a series of initiatives that widened our understand
ing of some wider aspects of Health Policy and Health
Care.
a.
the Bulletin responsibility helped us to focus
on a series of issues like Medical Education,
Child Health, Cost of Health Care, Environmental
Health, the nuclear epidemic, dams and their
effects on health. Workers Health, Pesticides
and Health, Nutritional and Health, and the
Bhopal disaster.
b.
a series of group reflections on Medical Educat
ion (Hoshangabad); Tuberculosis (Wardha); Tuber
culosis and Society (Bangalore); Bhopal inter
vention and evaluation of role of m—f—c (Patiala)
and environmental health - a case study of pesticides (Khandala) gave us opportunities to look at
other related issues with this growing community
■bps! •bb npr.qnArti vp
10
2.10
The Bhopal Disaster, one of the worst industrial and
environmental’accidents in history, became another
focus of study and action.
At the request of many
voluntary agencies and action groups working in
Bhopal, the medico friend circle decided to send a
team of researchers to conduct an epidemiological
and socio-medical survey and later a survey of
pregnancy outcome. The rich learning experience
included sunderstanding the disaster and the local situation
after the disaster;
assessing existing relief and rehabilitation efforts;
evolving and supporting a plan of study;
understanding the findings and their implications;
evolving a communication strategy on health issues
including ideas emanating from research efforts;
lobbying for relief and rehabilitation actions and
relevant type of research;
interacting with other scientists and the ICMR and
the medical establishment of Bhopal;
trying to get voluntary agencies and action groups
to work together on health issues;
evaluating mfc’s interventions; publishing reports,
communicating results and basically supporting
attempts to understand the problem and identify
action in a people-oriented sense.
Bhopal and post-disaster events and follow-up have
been a real life, case study - an open university of the strengths and weaknesses of various
initiatives by Government, professionals, non
governmental voluntary agencies and action groups
in the context of such a devastating tragedy.
11
11
The most important learning experience, however,
the need for process-oriented, socially sensistive^
community based epidemiological research for backing
ongoing efforts by non-governmental voluntary agencies
and action groups, This would greatly support the
demand for relevant health care policies and inter
ventions. These studies will not only help in lobbying
with decision makers but also in the use of the legal
system to stimulate social change.
More important
is the support it will give to health and development
activists, in basing their actions, initiatives and
movements on a sound and analytical information base.
A key learning experience of Bhopal which must be
stated is the inability of voluntary agencies,
health and development action groups and those
committed to the people to work together in solidarity.
The disconcerting experience in Bhopal - of mutual
suspicion and distrust, highlight once again an
important problem in the Indian development scene.
The dynamics of such networking are still to be well
understood but in part they were due to ideological
f
and personality conflicts.
2.11
Some reflections and action with the environmental
groups and other citizens1 groups, who have evolved
especially as a sequel to Bhopal, were also
interesting. In Bangalore, we have been in touch
Parisara — one of the local, environment action
collectives that formed up, post-Bhopal. The contact
has meant attending discussions, meetings, protest
marches and assisting in some nascent plans for
research. The groups supporting the peoples1
movement around the Harihar Polyfibre plant
pollution of Tungabhadra river in Karnataka has
also sought various types of informational/study
support for their work.
So also the rallying
12 ...
12
groups around the controversial social forestry and
eucalyptus issues. Whatever the other arguments/ that
need to be considered, to decide on relevant action
there is a growing realisation that one of the
effects of environmental mismanagement is an increasing
threat to the health of people and therefore a need
for community health action.
2.12
Drug policy issues and rational therapeutics has
remained an area where our role was primarily
catalytic even though there has been increasing
interest on the matter in Karnataka. Starting with the
group discussion - on a people oriented drug policy the Bangladesh Experience (led by Dr Zafarullah
Chowdhry of GK Project, Bangladesh) at the beginning
of our experiment, we continued our role by planning
special bulletin issues of the*Bulletin of Sciences
(Science Circle, Bangalore); medico friend circle
bulletin (November 1984 and December 1985); Medical
Service (November 1984; CHAI Journal), and a resource
file on Bangladesh experience (in coordination with
ISI Bangalore and Science Circle).
Many meetings of an evolving Karnataka Drug Action
Forum consisting of doctors, health worker, development
activists, consumer groups have taken place but the
process is still nascent.
2.13
Women's Health issues
in the context of the overall
emerging trends in Women's Movements in India alsp
became a new and additional focus of the cell. We
have been involved with the Bangalore based womens
groups in discussions regarding women's health and
the adverse effects especially on the poor women of
the present health and development model. MFC &
other womens’ groups have been active in the campaign,
regarding injectible contraceptives, and are now going
\
to focus on Family planning programmes and policies
in India at the next annual meet.
... 13
13
2.14
Planning, analysing and technically supporting studies
undertaken by many of our associates was another mode
of mutually supportive reflection.
These included the
study of Community Health Programmes involving village
Health Workers (Oxfam, Vanaja Ramaprasad); Study of
drug use/misuse in small rural hospitals (CHAI,
GD Ravindran); The Bhopal based studies (m.f.c).
Survey of Health Institutions (CHAI); and Health
4
Survey of a Karnataka District (Tumkur group).
2.15
An adhoc assignment which added to the evolving
a two
two week
week brain storming session
perspectives was a
an action plan for governmental/
with UNICEF on
non-governmental assistance in India for 1985-89 in
September 1985.
2.16
A few miscellaneous events were : -
meetings to discuss the WHO Document on the
Government/Non-government collaboration in
a.
b.
,
Co
Health care;
A meeting with-Oxfam .campaign unit - researchers on
drugs, pesticides, deforestation and dams;
meetings with a newly formed foundation, to
critique their idea of individual enterpreneurship,
in health and development and the need to shift
d.
focus to collectivity and teamwork;
discussion on approaches to Community. Health
with representatives of several funding
agencies.
14 ..
14
2.17
INDIVIDUAL INTERACTIONS
Whereas in paras 2.1-16. we have highlighted the
important groups reflections/action and study,
another very important and probably most worthwhile
dimension of this experiment was the time spent by us
with many individuals listening to their experiences,
sharing their plans and hopes, and providing them with
information and technical support.
We often challenged
some of their perspectives in a spirit of solidarity
and shared some of our own field experiences,
observations and tentative conclusions. This was
probably the most satifying and meaningful part of
the whole experiment.
in the packed schedule of a busy medical
Too oftent
college department, we were not able, in the past, to
give adequate time to all those who would like to share
an idea in health, plan an initiative or a project,.
reflect on their experience or just share the positive
and negative experiences of field involvement.
The Community Health Cell was kept very busy with this
dimension of work, apart from the initiatives mentioned
earlier. Many of the field level activists, who
contacted us, were often from outside Bangalore and
were constrained for time. Hence we tried to be
very flexible and followed an open-house policy
though this did mate the routine of the Cell
rather ’
hectic and somewhat exhausting, In
later months as a practical requirement to conserve
our energies for greater depth work and to improve
the quality of our support we were forced to adopt a
slightly more selective policy. The individuals
who visited the cell shared their experiences and
ideas but very often the supportive response
15 ....
(
15
from us included s-
a.
guidance/ technical support and references for the
various components of Community Health Work planning/executing health surveys, evolving
training programmes for village health workers,
planning a community health programme, evaluation/
reorienting methodologies, under 5-care issues
and so on.
b.
Rural placement/project placement support for all
those contemplating long-term, short-term
assignments in Community Health/rural hospitals/
peripheral institutions.
c.
Supportive planning of study tour, or electives,
by young medicos, interns, non—medical students,
pest graduates.
d.
Guidance to post graduate students doing field
oriented preject work for their theses.
eo
Alumni of St Johns' - both doctors and Community
Health workers, who would like to discuss their
current field projects/rural experience and assess
their own initiatives.
f.
A whole range of m.f.c. members and bulletin
subscribers reguesting information/ideas/
reference.
g.
Foreign visitors doing elective studies and
action/reflection in India - among other this
even included an acupuncturist from London
interested in the role of acupuncture in
h.
Community Health Work.
Colleagues/associates and friends in health and
development work sharing ideas/experiences from
time to time.
Informal support to ex-colleagues from St Johns'
in their current interests and initiatives.
..... 16 .
16
there were at least about
just to give an idea, in
Ln a year,
jv
150 such contacts,^came more, than once to continue the
informal discussions.
2.18
team development
The various inhouse activities of the team of our Cell
apart from those already described included sessions,
reference work, correspondence, basic secretarial work,
basic office assistance, reporting, communications,'
work at the press and so on. We ensured that the
team also got sometime to learn/appreciate/understand
various dimensions of the experiment.
This was done through informal discussions on each
of the interventions, pre- and post-event. Also by
some planned sessions to discuss relationships,
job satisfaction, decision making and other
aspects related to the working ethos of the cell.
These greatly helped to. evolve an increasing
participatory decision making precess in the Cell.
(Refer CHC-III for further details).
The team members also attended short courses and
ad hoc training sessions as part of ongoing staff
development and enrichment.
These included diverse
topics such as IwW cost communication media like
puppetry and posters; a basic course in mental
health; scriptural inspiration for liberation and
freedom; scientific advances and practical problems
it
in Natural Family Planning; group sessions m
self-analysis and self-actualisation. Individual
team members made their own choice of courses.
17
%
1
17
2.19
CoiniDunity Health - A collective perspective
In August 1985 at the request of the ISI a short
paper on Community Health as a quest for an
alternative was prepared putting together some key
issues identified in our study-reflection. This
was included in the special issue o^ Social Action
on the theme — 1 The Health System in India*. Later
it was added to a collection of experiments with
participation and non—formal education focus, and
included in the book ’Development with people1*
This preliminary article was circulated to twenty five
colleagues and associates to elicit critical
reactions and comments, and evolve a collective
perspective o
2o20
Review and Evaluation
From February 1986 — we began to review the work of
the past 26 months and wrote a report to highlight
the main initiatives and learning experiences and
plan more concretely, for the continuation of such
an effort.
This report was sent to the three members of our
wise-council in’ March for an indepth review and
comments.
A two day meeting was organised in April 1986
when this draft report was discussed in detail and
the critical comments as well as other observations
of the wise council was considered. From this
crucial meeting a short term plan for a 18-month
staff training phase and some long term perspective
plans emerged which were initiated from June 1986.
*
18
... 18
the Future
3.
Some thoughts on
3.1
Critical questions
The 'Community health cell' was an informal study-,
reflection action experiment - evolved as a tentative
strategy to understand an ongoing process in develop-
went. It was not intended that this strategy
should automatically grow into a more formalised
or institutional initiative.
Therefore from the
very beginning it was decided that a mid-course
reflective-evaluation would be organised after
about two years to take stock of the experience
and plan future directions.
During this experiment we came accross many people
and initiatives working for Community Health at
grass root level and many other individuals and
initiatives supporting this process through training./ planning/ evaluation, networking, communicatA process of action and a process of support' was alrcady present and evolving.
The main questions however - were. What were the
ions and research.
additional supports that this ongoing process
needed ? what were the lacunae of the existing
supportive systems ? what were the actions that
needed further strengthening ? What could be the
role of a team like ours, in the future ?
I
3.2
A documentation Cell
Inspite of the many adhoC/ ongoing initiatives in
documentation/ we still perceived an urgent need
for a comprehensive/ specifically Community Health
focussed documentation cell.
19
19
a.
Keeping track of materials
Such a Cell would need to keep track of health
related publications, bulletins, newsletters,
occasionl papers, research studies and government
non—government agencies reports arising out of the
rich ongoing experience in the country.
It would be crucial to establish close links with
initiatives such as Voluntary Health Association
of India, (New Delhi) Centre for Education and
Documentation (Bombay), Centre for Science and
Environment (Nev; Delhi) and the Indian Social Insti
tutes (New Delhi and Bangalore) to keep track of
documentation efforts.
Locally in Karnataka, a
close link with documentation centres in Bangalore,
and Libraries of research institutions, university
departments, directorate of health services and
medical colleges should be established.
These national and local links wohld be aimed at
ensuring access to available materials and documentation/collation Efforts with the minimum of
duplication.
t>)
Materials in Regional LanguageMuch of the materials especially in the non-govern
mental Sector is still predominantly in English and
this is a sad commentary of the distance of the
existing communication efforts
the people.
A major thrust of the documentation cell should
therefore be
1) identification of all available materials in
Kannada, Tamil, Telugu, Malayalam and Marathi the main language groups in Karnataka.
11)Facilitation of translating key documents and
reports into Kannada - to begin with to ensure that
collective reflections can be stimulated at levels
more firmly based in the community.
20
o.. 20
C) Distribution of Documents
Facilities for cyclostyling and Xeroxing key
documents at low cost for all those interested
in the process of Community Health is also an
important need* Stocking of key publications and
handouts produced by other organisations in
Karnataka and India, for distribution and sale
.could also be a key function but this needs
some planning and basic infrastructural support.
A Communication and Continuing Education Cell
3.3
The ongoing process can be further supported by
a concerted communication strategy which must be
directed at atleast three levels?-
a) Lay - Awareness Building
The level of lay people - rural or urban with
whom the ideas, issues and perspectives in
Community Health need to be'shared to initiate
a participatory dialogue as well as a crucial
process of demystification of medical and
health matters.
Ongoing initiatives such as the Karnataka Rajya
Vigyan Parishat, non-formal education and adult
education efforts of voluntary agencies and•
government organisations, science education
programmes organised by voluntary agencies, and
various extension education efforts by workers in
the health and other sectors of development could
be partners in such efforts.
b)
continuing education - to team members of
health action projects and initiatives, as well
a
as to the staff of the government primary health
centres i® another crucial venture.
21
21
While the former has to be a new venture organised by a networking effort of existing Community
Health training organisations in Bangalore, the
latter will have to be a process initiated with
the directorate of health services as a pilot
scheme in possibly one district.
Two crucial contributions, thatNGO's involved'
in Community Health can play in this pedagogical
intervention is 1) the facilitation of a more
appropri ate, group sensitive, participatory,
problem solving pedagogy that they have gained
experience in
11) the facilitation of an under
standing of health bey ond the purely physical,
technological and organisational, dimensions that
characterise the present educational efforts.
The absence of both these factors at present
make the so called 'Health Education' efforts of
both government and non-governmental agencies in
effective and somewhat counter productive. This
continuing education effort would have to be
supported by audio-visual skills as well pedago■gical skills oriented to distance learning.
c) A communication of Community Health - issues
ideas and perspectives to key decision makers in
the state - politicians, administrators, technocrats and leaders of trade unions and pressure
groups to ensure that 'Community Health* is
brought into the focus of 'development debate'
in the system. This would also ensure that
decision makers begin to see ‘Community Health*
in its broader perspective and not in its
severely myopic medicine- doctor - hospital -
medical college perspective that is popular at
present.
22
c 22
3.4
An Action Research Cell
A large amount of present day community health
action is adhoc. The issues identified are important but the methods employed to determine
justification for action are often 'emotional'
rather than on a collection, organisation and
critical interpretation of data on the local
problem or social reality.
There are times when
issues get referred for legal action or are parts
of representations or demands to the governmental
agencies for action.
At these times particularly
it would be a great help to an evolving action
programme or initiative that well researched and
well documented facts are available to them to
support their efforts.
There is therefore an
urgent need to make available such expertise and
back up efforts with socio-epidemiological field
investigations.
In many ways this would actually
be a sort of 1 counter-expertise' available to the
community since research efforts by many of the
existing in-system institutions are coloured by
certain unchallenged assumptions about social
reality as well as operate under controls which
make information inaccessible to the people.
There is therefore a need for an interdisciplinary
team which has the basic skills, creative flexi
bility in approach and the social sensitivity to
tackle the challenges of grass-root level investi
gation. The research endeavours initiated or
supported by this team must not be super imposed
upon existing action programmes but must be
adequately participatory and accessible so that
'health action initiators' as well as representa
tives of the communicy can appreciate the problem
solving approaches IQ socio-medical-epidemiological
*7
investigation.
23
23
Not only would the problem solving methodology
and ethos, thereby become part of grass-roots
y*
organisations but the researches, would also be
A
continously challenged in their efforts to collect
and interpret data and to ensure that certain
assumptions of present day research design and
■
methodologies do net go unchallenged^
A wide range of issues can be studied by such
a team.
These would be identified by existing
organisations or even by the research team
members during their grass-roots contacts or
team reflections.
From the experience of the Community Health Cell
many issues were already beginning to emerge.
i)
Health and nutrition effects of development
policies such as present agricultural policy,
social forestry etc.
ii) Accessibility and availability of existing
health services both governmental and non
governmental to different sections of the
community.
iii) The health culture of the community and its
attitude, utilization and perceptions of the
various, modern and traditional alternatives
available to it.
iv) Health effects of environmental pollution
caused by industrial effluents particularly
along water courses affecting villages down
stream.
v) Health of occupational groups and marginalised
sections of existing rural communities.
vi) Studies of participatory and problem solving
pedagogical innovation in training programme
and non-formal education efforts of existing
■
voluntary agency initiatives
The possibilities are enormous.
V
24
24
3.5
NETWORKING
There is a great need for networkingamong a whole range
of existing efforts so that some or most of the above
needs can be met by supportive initiatives.
The networking should involve s
Grassroots - health and development action groups;
a.
b.
Health projects especially under voluntary agencies’
c.
auspices;
Training, communication and coordinating agencies,
associations and initiatives;
e.
Non-formal education, adult education and
science education experiments;
Socially sensitive ’academics’ and 'professionals’
f.
in the health related sectors;
Socially sensitive elements among planners and
d.
9
decision-makers;
g.
Health oriented elements among pressure groups
such as Trade Unions and issue-raising movements
such as the environmental and women's movements.
h.-
Socially sensitive elements in society and their
organisations who can promote health perspectives journalists, teachers, lawyers and so on.
It is important to clarify that networking need not
mean coordination in any ‘big-brother’ or
organisational sense.
We basically feel that
networking should imply a coming together to
dialogue, share information, and experience, discuss
issues and evolve common perspectives and all the
existing forums should be made use of to the
maximum extent possible. As and when common action
initiatives emerge, these too could be supported
by ongoing available organisational frameworks
rather than seeing the need for a distinctly new
and identifiable networking organisation, in
every case.
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25
3.6
In summary then the Community Health Cell's studyreflection-action experiment has led to the development
of certain broad perspectives on Community Health which
^are described in great detail in a* separate publication
to be brought out by the Centre for Non—formal and
Continuing Education, Bangalore.
$
In addition the study reflection has led to the
identification of the following basic initiatives
required to support the emerging and on going process
of Community Health in the States
(a) Documentation
(b) Communication and Continuing Education
(c) Action research
(d) Networking
Our assessment of the situation in Karnataka has led us
to conclude that initiatives (a), (b) and (d) can be
evolved and encouraged by bringing together e large
number of individuals and ongoing projects already
involved in supporting action. By strengthening existing
initiatives and evolving a greater collective dimension”
among them, it is possible to increase the availability
and accessibility of these supports to a larger number
of group active at the community level«, These supports
would include skill training, planning and evaluation,
group building efforts, audio-visual communication
and so on. The collective dialogue and discussion
initiated would also help in focusing ongoing initiatives
in more crucial dimensions and directions.
4O
TOWARDS AN ACTION RESEARCH CELL
The CHC team has decided that the development of an
action research cell which has both the skills and
creative flexibility to meet the challenges of field level
investigation will be the primary focus of our efforts
from June 1986o
26
4.1
The skills of such, a research team will be primarily .
geared to sociological/epidemiolo. ical field investi
gations. Other 'Skills and technical facilities reguired
to back up epidemiological enquiry can be tapped from a
large number of existing organisations witn which
loose but effective linkages can be established. The
Cell *will bring together researchers who value and
appreciate involvement in field based investigations,
and have the social skills and attitudes to work with
people in the community, most often focussed on the
more marginalised sections, in what can often be
difficult field conditions. This pro-people ethos
and a social sensitivity are.crucial to such a Cell,
if it aims to go beyond the traditions of existing
■medical res.arch institutions and support in a
participatory way, ongoing community health action.,
Various possibilities will have to be considered
in terms of a long term viability of such an action•
research cell.
(a) Type_of Research
Whether research undertaken will be primarily at
the request of ongoing projects and initiatives or
will'the research cell have long term research
interests of its own? Probably a mix of both
4
these types of research projects will have to be
considered.
(b) Structure of Team
What will be the basic structure of a nuclear
or core team? How will other resource persons
interested in specific projects or problems be
involved in .research efforts even though they may
be based in formal institutions and other projects.
Flexibility in the concept of participation and
support will be a crucial requirement.
27
27
(c) Funding
What funds can be tapped to support action
research efforts? As an overall policy
it seems that efforts to tap governmental funds
like those from the Department of Science and
Technology, ICMR, ICAR, ICSSR, Karnataka State
Council of Science and Technology have to be made.
Private trusts and research foundations and grant-
in-aid to NGOs from government departments of
health, education, rural development and social
weltare will also have to be considered.
Foreign funding agencies supporting health and
development initiatives in India could be tapped
for certain specific supports such as books and
publications but this should be with caution and
only if it possible to get it without the existing
charitable, paternalistic, project projecting and
project imposing relationship. Some agencies value
a more participatory relationship and could be
consioered. Smalx inciividual based support systems
will also have to be considered since funding could
also be a consciousness raising exercise as well
as a symbolic participation. Ultimately an aware,
socially sensitive supporter is better than an
ad hoc charitable donor.
Whatever the source of funding a strong emphasis on
simplicity, low cost efforts, - non—duplicating and
non-waste strategies, resource reuse value systems
will be constantly encouraged.
(d) Base__of operations
The CHC team believes that it may not be absolutely
necessary or inevitable to formalise this initiative
by registering an independent organ! etion in the
future though this may have to be considered if no
other alternatives emerge in the next 18 monthso
i
9R
.
28
It may be possible to relocate this initiative
in a larger, ongoing health oriented initiative,
•research institution, teaching department, educational
institution or coordinating organisationo However,
a creative autonomy and a participatory governance
will be pre-requisites to ensure that some crucial
features of the search and some aspects of a new work
ethos can continue to be experimented with as part
of the action research.
We do have certain misgivings of relocating in
a larger venture, primarily around the following
questions s
(i)
Can institutions/projects built on existing
value systems/modes of functioning appreciate,
support or nurture the sort of creative
flexibility such an initiative requires?
(ii)
Can governance mean a participation in
a process of discovery rather than a control
or an authorization in the traditional sense?
(iii)
Will institutional needs and objectives and
the fears of precedence, over-ride the
exigencies of an evolving, exploratory
process?
(iv)
Can institutions/projects committed to a
*medical model’ and concentrating on
’provision of services' support a paradigm
shift in efforts toward a ‘health model’ and
an ’enabling* orientation.
Notwithstanding our misgivings we are still
convinced that a serious effort should be made
to locate our effort.'
in the context of an existing
ongoing initiative rather than launching off
on yet another centre.
29
✓
29
5.
IN> CONCLUSION
The Community Health Cell (CHC) was an informal
study
reflection—action experiment in Karnataka
State which began in Bangalore in January 1984. The
main objective of this experiment was to understand
the dynamics* of Community Health action and to get
an overall perspective of the sitution in Karnataka.
As a basic methodlogy, a small team (three of whom
were previousJLy members of staff of a department of
Community Medicine in a medical college in Bangalore)
participated in reflections and supportive actions with
a large number of health projects and development
initiatives organised by non-governmental voluntary
agencies in Karnataka. It was hypothesised that with
the ‘researchers’ and the ‘activists’ participating
in commong reflection and action a more comprehensive
understanding of the community health process would
emerge. During the ensuing months the CHC team also
shouldered the organisational responsibilities of the
medico friend circle, an all India voluntary network
of doctors and health activists trying to evolve health
care policies and medical education policies, more
relevant to the Indian context.
The experiment was concluded in June 1986. The study
reflections are being published in a report entitled
Community Health—the Search for a Process. The CHC team als
also identified the needs for a documentation effort,
a communication and continuing education effort and a
networking effort to support and sustain the
ongoing ‘Community Health1 process emerging in
Karnataka. These, howjever, did not necessarily need
a distinctly independent effort but could very well
30 ...
30
(
be brought about by strengthening existing initiatives,
training centres, coordinating groups and encouraging
a greater collective dimension in their efforts.
A crucial but unmet need was action research
primarily socio-epidemiological to support the ongoing
health initiatives and the evolving issue-based
movements in the community.
The CHC team has, therefore, decided that the initiation
of an action research cell, which will promote a wider
appreciation of socio-epidemiological perspectives
in problem solving in health, health care and community
health action, will become the focus of its future
activities.
*******
*******
***** *•*
*******
*******
*******
*******
1
31
5.1
Publication of Regort
As part of a process to initiate a collective
response to the study—reflections of the CHC team
a cyclostyled report entitled ‘Community Health —
♦
the Search for a Process’ will be brought out by the
Centre for Non—formal and Continuing Education in
Bangalore in 1987. This report will includes
(i)
a background note on certain important
developments in India in the years 1972-1986
to place the reflection in the right context;
(ii)
A short note on methodological issues;
(iii) The reflection on Community Health in India;
’
(iv)
The principle's of Community Health arising
from this reflection;
(v)
A series of important tasks for the future;and .
some ap; indices to highlight the sample of interactions
from which these reflections are derived as vzell as
reading and reference lists.
This will be sent to our colleagues and associates in
Karnataka and other parts of India to.generate responses
that will help to sharpen the focus of our future efforts.
The report will also be available to all who are
interested Ufa a modest, reference document on Community
Health in India.
5.2
Phase II of Process
The CHC team has now moved into Phase II which is
an eighteen month planning, training and staff
development phase. June 1986—December 1987. During
these 18 months members of the team will pursue
32
(
32
courses to equip themselves for future action
research.
During this phase many aspects of the study—reflection
will be documented and some critical reflection and
approaches on possible future areas of action'research
*
will be generated.
Ideas arising out of the study-reflection will be
shared with colleagues and associates and various
dimensions of future action will be discussed.
Explorations for future base, financial support,
core team and Research perspectives and methodology
will also be undertaken.
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