RF_COM_H_37_SUDHA.pdf
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OF .VOLUNTARY ORgA NI SAT! Oj\l S IN HEALTH AND HrA LTH CARE SERVICES
CHAI
study team,
Community Health Cell, Bangalore,^
15th April,1993.
1
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 come from
diverse backgrounds such as sociology , theology, different
branches of medicine, nursing, community health, communicat ion,
law, education, developitent 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 guestion was out
t°_the_Eanelists_reaardina_the_role_of_v 2luntarY_organisations_in
i----i-!i!itt!_£§.sgect_t o_heaIth_and__health_ca re_duri ng~the''next'Tifteen_years.
Thirty-seven panelists (75.5^) responded. AA summary
of the different ideas that emerged is given below. This parti
cular guestion was not taken for the next round which focussed
particularly on the role of CHAI. Therefore, no prioritization or
ratln9_0^' the ^eas/issuas has boen done. For the purpose of this
note similar ideas have bsen put together in broad groupings,
Hr. st
of ths colas identified are already being played to greater or
lesser extents by different volags or NGO's 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
IJhat COLJ1" Or 3hould be the areas of .gr i or ity d ur i ng the next
Arriving.at sone 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 role of volags are :
1) Priority groups for focus of health
related work
2? Varying types of intervention.
3) Hethods of work,
4) Methods for spread of ideas.
o o 2
x‘ CHC,
326,
Society for Community Health Awareness , Research and Action,
V Main, I Block, K orarnangala , Bangalore 560 034.
Paper prepared for a meeting organised by CHAI
Trainers 1:1.n ^ne 1993 at Sangalore. It is an of Community Health
analysis of Question:
Three nf the
-- 1st round of Policy Delphi method of Research.
I o
Priority groups ^!3r.^ogus o f\ h cal t h j? 21 a t e d~u or k ~b y
1.1
Need 10 focus on and support the poor and marginalised
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Special focus on the rural and tribal poor and bn urban poor
living in slums.
There is a need to identify neglected groups
among the population,9 especially those that depend for their
livelihood on .the fragile eco-system.
intervention need to be evolved.
*
Strategies of work
There is a need for a preferential option 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 cars
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 sccial security
for the poor are effectively implemented.
*•
While working towards greater justice for the poor,
poor volags
should also work towards overcoming the difficulties faced by
the 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.
Need to care for. specia 1 groups:
Those groups mentioned specially were:
a1 Girl Children and women - there is need for: educ-ation 3nd
special health care to counter the anti-girl child bias in
our society, Education and- advocacy towards empowerment of
women is required,
The health status, infant mortality and
population growth, not to mention the economic status of a
commiinity changes in a positive direction when women are
educated and have a significant say in the matter of social
.decisions etc.
b) Tribal gr oups.
c) Patients suffering from AIDS and leprosy.
..3
II .
Varying types of ,1 ntervention. by uolags:
2..1
Provision hf services - secondary and tertiary prevention0
Examplea given w.ere as' fnllows:
*■
Mobile clinics in endemic areas for diseases like 1eprosy,
filaria etc.
Half-way. hospitals closer to the community with facilities for
■ surgery etc, so that chronic diseases can be tackled §t the
community level.
*
Services for the physically and mentally handicapped and the
$
■aged.
* Rehabilitation
and supportive services.
*
Counselling services.
*
Treatment centres for alcoholics and drug dependants.
* .Ho spices.
Promotion'of preventive and promotive, health services”
2.2
The following specific.areas were highlighted:
*
F oc us on all preventive andpromotive health work, i ncl ud i ng
mental health. .
*
Propagation of healthy f ood ha.bits, diets and exercise .f or. a
bet ter -quel ity ■ of'"life."
*
Nutritional programhies to deal with nutritional, deficiency
• diseases.
*
Prevention of communicable diseases.
*
Effective implementation of the principles and components of
primary health care through appropriate strategies for the
attainment of Health For All.
Promoki.on of. cnmmunity health and development .
2.3
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There is nee‘d to work towards community health rather than
institutionalised health care,
to focus on general heal th 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 comrnuhity health orientation.
..4
a
* Community-health care programmes for marginalised communities
with their participation, is liberative. Liberation of people
t%kes place when communities of people take their lives into
their own hands.
* People should be empowered to do things for themselves by
making them realise their self worth and by a building of selfQonfidence. Thus people can be helped to be makers of their
own guality of life.
* Health problems should he tackled within the family,' the
community and locally as far as possible.
*
People should Le helped to prevent illness and promote health
through their oun organisations.
* 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
^safe) drinking water, nutrition programmes etc.
* There is also need to provide and to pressurise government to
provide for basic health needs and clean water to all.
Promotion of newer dimensions of health work/he'alth care;
2.4
The
newer dimen.sions mentioned included the
followings
* The wholistic approach to health in which proper priorities are
given to spiritual, moral, medical, social, economic and environ
mental factors.
Evolving and promoting the wholistic approach by
bringing together practitioners and researchers of various indi
genous health systems.
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Use of
non-drug therapies.
■^Promotion of positivs- health "and natural methods of health ca re.
^People should be enabled to rediscover experience, knowledge,
skills and-practices within their communities and give a scienti
fic basis wherever possible to strengthen what is wholistic and
•healthy o
^-Promotion of an enthusiasm among people to build their own
health system in which they are the primary planners and the
real implementors. The authentic result of their health care
will be founded on their innate sense of community traditions,
simplicity of life style and self-reliance.
. .5
*
Demystification of health, so that people can use what is
available,9 accessible and acceptable to them.
*
Developing natural
*
facilitation tf consumer movements.
resources in the field of medicine.
Promotion of a rati rnal/sc ientific approach to health care
2.5
planr.ing :
*
Need for re-assessment, re-prlentation and rejuvenation of the
considerable voluntary health sector in India. This system is
relatively large in India,9 but on the whole deteriorating, in
appropriate and wasted.
*
To make a cb nstant (continuing) analysis of society and the
•health system so as to bring about policy changes in the re
structuring nf health services.
*
Provision of cheaper and people’s need oriented health care by
not expanding hospitals into specialised units.
*
Developing a system where a few hospitals in each region could
make sophisticated techniques available at reasonable prices.
*.. . T.o. eot.a.blish a liaison netcork with apornpriate leaders at
different levels to monitor preventive action.
To establish a network of epideminlogical research centres to
frreuarn various diseases0
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Need to develop regionalised health services.
To work out a
proper divergent type nf referral system wherein specialists
from larger institutions move out to smaller institutions and
provide specialised services.
•K
Need to develop methods for simplification and rapid -diagnosis
nf common diseases.
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The management of health care institutions need to be profess
irnalised using scientific methods.
*
To work towards legislation that protects and promotes good
health, e
.g.,, preventinn of pollution,provision of safe drinking
e.g.
water, et c .
*
To challenge strategies being followed for ’Health For All
like the G.O.B.I. package (growth monitoring, oral rehydration,
breast feeding and immunization) and the targetted Universal
Immunisation Programme.
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*
Influencing policies using scientific evidence and through
building up public opinion.
*
To promote/develop innovative, appropriate, feasible and cost-
effeetive--programmes' in health carej education of health professionals/personnel, and 'in'devel.opmerbt'.
* To involve para-professionals and non-professionals in health
care.
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Responding to emerging hoslth problems and newer hsalth issues’
2.6
*
health
Si nee Government is likely to focus primarily on public
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care, volags (NGO's) should be the' initiators of newer response^
services for emerging health problems.
*
The problem of- AIDS prevention and controlcare of AIDS patients,
including running hospices for them, is one such new problem.
as being important.
n
* Health effects of industrialist/consumerist expansion.
•*. Environmental health issues are also emerging
*
The pre sent. systr m could be . challenged by involvement in issues
like the production' of essential drugs, campaigning against un
necessary and harmful drugs andchemicals, challenging practices
of multinational drug companies and hospital corporations and
the Tnisuse of advertising. There is a need for de-medicalisai^on
of society and dsmystificatibn of-.the health profession-.
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Prompt ion o f
* To
i ndige nofeis a nd alterna t ive systems of medicine;
help rediscover health systems/ho'alth practices that are
indigenous and effective, because they are related ro the life
sit uat ion, culture and ambience in which people live,* To educate
and demonstrate to people the
efficacy of herbal
medicine and to instill confidence in them that basic
health
cafi be within their control in normal circumstances,
f:
* To judiciously use alternative
systems of medicine
so as to
provide the best possible health care in different areas and
situations.
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To uphold and promote higher ideals in health care:
2.8
* To
keep alive role idealism, humaneness and a holistic app
roach in health care. These are the essential 1 leaven 1 to
counteract and challenge the proliferation of mechanistic,
commercialised and depersonalised medical/health care.
*
Volags should resist the temptations of competing with pri
vate commercially oriented health institutions which are
primarily concerning with making profits rather than ser
ving 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
and to ensure the delivery of services.
* To be
vigilant against malpractices and to mobilise public
opinion against such anti-social activities.
2•9 To develop innovative programmos/approaches:
* There is
a need to teuild 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.
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By providing services where there are‘none and documenting ex
periences and information that are thus generated, another imp
ortant purpose of policy critique will be made possible. There
is a need for volags to provide critical comments on health
policy and advocate changes found necessary by the data genera
ted a bo ve .
*
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.
. .8
*
To develop close interaction with the State so that entire
Blocks/Primary 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 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
systemfor dissemination and adoption.
* All resources among NGO’s could be combined to establish regimal
centres for production of generic drugs, manufacture of hospital
beds, equipment, bandages etc. Sheltered workshops and voca
tional training centres run by NGO’s could be utilised to provide
infrastructure etc. There is a guaranteed market both for drugs
and equipment in NGO/Church hospitals,
s, provided quality,quant ity
and price requirements can be met. This would help in cost re
duction, employment creation end production.
*
There is a need for reorganisation of medical education.to pro
vide 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.
* There is a
need to find suitable ways of combining the excellent
ideas of the basic philosophy of VHAI (1978), ACHAN (1981), CHAI
(1983) and CHAI (1966),
III. Hethods of intervention/involvemont in health work:
There is an overlap between some of the issues raised helou.
There are a wide range of suggestions, some of which may appear
contradictory and represent differing approaches.
3*1
Health activism and community organisation:
* Promotion of genuine people’s movements.
* Uolags should support activists in the field.
*
Support to people’s movements, organisations and associations,
so as to bring pressure on the government to work andto be accoun
table. Organising people and mobilisation of public opinion to
put pressure on the system for a more just provision of services
and for a revision of government priorities so as to emphasise
the health of the poor.
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* Need1 for awareness building, education and' organisation'-ef-—
people in communities toL critically understand thecitz "si.tuition
and tn- act In Tt' unitedly at the-loc'-'l level .
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* To enable people to develop and express their oVn- ideas^nre-—
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garding- health and healthy communities.
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To .enable •- people tp ,.r
organise thatrr’sPlve s t ' provide their' own -hnalth- servicpsvtnd to
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....styles within a ■self-reliant
- . devejoo
lite'
mode, that is to
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; "take health back from the.
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lt echnocrats T.
.*■ Campaigning towards bringing in legislation to ensure a'ccountabili ty .and, transparency in the functioning of government (and
its. .health systems).
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a ^iGonscieptiising j-and ppg.anioi ng - consumers against unhealthy .
/p^acitideot ■
Qainging gbout' a .change’ in ^societal -attitudes re-
;.:ga^ding\bgrTaG'nerisra?. -pro fi tearing TaRd. cultural alie-nat ion
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* Working towards community participation1 in Health^vcaie^^- 4 "• >;
* Mobilisation of
people as volunteers-in the neighbourhood to
take care of the health aspects of tha t area.
Network ing’
ii)
* To develop, working relat idnsh ' ps - and a.n effect 5. vc network with
activists and other groups i-nvolved in issue rais ing/lobbying/
advocacy work in the field of health, education, agriculture,
technology andscience. This is. for mutual support, encouragement
and solidarity.
ill) Co-ordination:
* Co-ordination of programmesfor health care (between volags) to
avoid duplication and to help bring about better utilisation
of services.
* Inter-sectoral and intra-sectoral coordination of services.
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Collaborat io n:
To work as partners with each other and with government towards
achievement of Health For All.
*To collaborate with government in improving the level of effi
ciency and quality of services at governmental hospitals and
health centres.
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.Liaison:
v)
-x- To be a link and bridge the gap between the community/public
and the health authorities o^ the government sector to improve
understanding,
explain constraints etc,.
This liaison would help
’government facilities’
people to get access to
structive,- non-th??eatenino appreach.
using a co n-
Thus people
will not have
to. suffer when a vclag/NGO withdraws.
Research and Evaluation:
vi)
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documentation and evaluation :jy vo.Lags.
* To promote research,
* To undertake
identify emerging-health issues and
research to
to develop naw solutions.
* To develop appropilalo technology through a process of
and research
bo deal
with various health problems.
To promote st ud y/analysis, of
cularly the
* To
social and health problems,
parti
aspects of hearth..,
social
onduct operational
research and
•n our-
p bi nt the 1a cuna e
■K
st udy
To help i’n generation o.
undertake
studies to pin--
system,.
national, data about health changes
occuring at the comm-unity re\/el.
T’o study alternative' systems of medicine and their of feet so
promote s ysteins research in tb.e efficacy of
-x- •Research and evaluation oP
To
i. I ba q re. t a d me d 1c i ne *.
ongeing projects.
Voluntary hospitals
in general are requleed to do a lot of self’ -analysis and 'te-
examination of
their role,
6 b j e.ct i ve s ano a re
Many of them have
outlived their
not clear about their philosophy,.objectives
and goals in the context.
of cur-rent changes and developments^
need to re-examine their service effectivehess,
There is a
cost
effectiveness and quality of service
gt h o d_s for sp re ad _of id ea s_
VI.
Advocacy / L. a b b y 1 n g :
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Advocacy can beat tuo levels?
namely:
a)
by networking at the ma or q- -level far health and social justice,
b)
by education,
ties get
organisation and deveiopmeiit - to help communi
bettc:c health care and services rrem the governr.env.
Thia is cost effective .end has uidesp^-eau effect
i '
* Volags should lobby as an active group to influence th.e social,
economic and political policies of the government, which may
have direct and indirect effects on health and health care
1 services.
*
Among several areas it was suggested that advocacy for respect
ing human life needs to be taken up.
*
A strong lobby •needs to be built to. regulate the standard of
operation of health services.
* Need-for a lobby group to influence governmental and voluntary
organisatiops - to maintain the capacity and quality of the medi
cal profession.
* There is a need for information diffusion with greater media
coverage to highlight health andsocial problems.
4.2 Creating critical awareness/eduoat i on
* Voluntary
agencies need to create a deep and critical, awareness
amoQg people at the grass-root level about the real economic,
political gnd soci-al situation prevalent in the whole country,,
Once awareness has been created people'must be helped tp organise
themselves to demand their rights with regards to heal th.housing
and education.
Because in any system, changes will never come
through people, at the top or even at the middle, . but4. at the
bottom.
Vplags could facilitate the’intsriorisation of the value of
educat ion, knowledge and" Ih rning for liberation from exploita-
tion and deprivation.
*
Needs for education regarding the rights of people, without .
causing harm to the community and which helps with preserving
the good value based traditions that exist.
*
Need for"awareness building among the public about the deficien
cies
and exploitative nature of the health system prevailing
»n our country.
*
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Since, according to WHO, 80 per cent of illnesses in developing
countries arc preventable, the voluntary health sector should
concentrate on health education at the village level.
>
* Piss^raination
of* health knowledge and expertise and the process
of leraning to the deprived sections of society through the
media.
*
Need- for an emphasis on the promotion of health and the ways and
means of achieving it,
through education.
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*
L'aed to focus on the social aspects of health, in education.
*
Physical and mental health education with focus on teaching of
traditional .health care methods like yoga, meditation etc.
*
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Teaching • ofs elf-help , health care methods.
* Awareness huilding regarding sanitation, '
*
Education to present AIDS and addictions.
* Education
to: maintain a correct and healthy attitude to- the medi
cal prof assion,both among the public and among medical people.
* I nt roducdJn'^’ effective machinery for health education.
Literacy along with hcal-t-h„ care programmes.
*nAdult education in rural and tribal areas with health components.
*
Public, education for information sharing and action.
* Increasing the -use of mass media for health education.
4.3
Trai ni ng:
*
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Need for training at the- gross-root' level and in theiformalsector.
* To evolve training programmes to equipnural women with health and
medical expertise,
so that they can dissemi nato : he al th information
artong the people.
* To enlist motivated and appropriately trained bands of committed
health workers at all levels, that
is to train various cadres of
para-medical personnel in health care.
* Greater need for
non-phy sic.i an,
health personnel developrren t with
emphasis on .proper health management.
* Need to improve the commuiication skills of health workers.
*
Need for formal and
non-formal training of resource personnel
for
holistic health promotion.
*
Preparation of appropriate teaching aids.
There are over four hundred' voluntary organisations WDrking for
health in the country.
This does not include the mere informal health
related work done hy interested groups and people.
The contribution
of the voluntary sector is substantial not only in number but also in
nature and type
mitted.
f work, whioh is often pioneering, creative and com
A very wide range of roler, functions and methods of work have
been outlined by Delnhi panelists as being necessary and relevant 'for
the future.
Several of these ideas are already being done by various
groups.
Inclusion of those ideas into' the training modules and'pro
grammes of those involved in community health training mayb-be-rp^eVant.
Again, some groups may have already introduced these ideas "into-their
training programmes. Sharing of methods would, be beneficial;
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4
^STRENGTHS
01.
LIBRARY AND DOCUMENTATION UNIT
02.
GOOD NETWORK OF CONTACTS (AT ALL LEVELS) AND
STRONG CREDIBILITY WITH THEM
03.
WILLINGNESS
TO
RESPOND
TO
NEEDS
INDIVIDUALS / NGO / GOVT (AT ALL LEVELS)
04.
ATTRACTS PEOPLE ORIENTED TOWARDS A PARADIGM
SHIFTED / OPEN TO NEW IDEAS
05.
INTERACTIVE WITH INCREASING NUMBER OF MULTI
DISCIPLINARY PROFESSIONALS
06.
NON HEIRARCHICAL TEAM WORK (DEMOCRATIC /
PARTICIPATORY)
07.
SCOPE / SPACE FOR INDIVIDUALS CREATIVE GROWTH
(FLEXIBILITY)
08.
KNOWLEDGEABLE
/
EXPERIENCED
APPROACHABLE SENIORS
09.
FINANCIAL TRANSPARENCY
MANIPULATED
/
HUMANE
ACCOUNTS
ALSO
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Responsive to emerging concerns
•
perspectives based on Indian Experience
•
Promotion of Baloonist approach / Equity / Empowerment
•
Secular; total freedom in work; Planning well
OF
NOT
*Q i
01.
SHORTAGE OF TECHNICAL PERSONNEL / SECOND
LINE TEAM
02.
EXCESSIVE BURDEN / WORK LOAD AND CHANCES OF
BURN OUT ON FEW TEAM MEMBERS
03.
PROBLEM OF TIME MANAGEMENT BECAUSE OF OPEN
ENDED CATALYST APPROACH (“MORE THAN WE CAN
CHEW”)
04.
TOO MUCH CATALYST ROLE MAY MAKE
UNWILLING TO TAKE ON RESPONSIBILITY FULLY
05.
NOT EXPLORING ON ALL RESPONSES / IDEAS
EVOLVING
FROM
PARTICIPATORY
ACTIVITIES
(CONCENTRATION ON TRAINING AND POLICY ONLY)
06.
LIBRARY POLICY IMPLEMENTATION
LOAN POLICY NOT STRONG
07.
PRESSURE ON TEAM DUE TO
US
ESPECIALLY
• SHORT NOTICE / REQUEST
• LAST MINUTE WORK LOADS
• LACK OF FOCUS ON WORK
SELF RELIANCE IN FINANCES / HUMAN RESOURCES NOT ENOUGH EFFORTS AS YET
08.
ALSO
•
Conflicts between humaneness and professional functioning
•
Individual roles overlap
•
Excess flexibility / freedom leading to anarchy / non achievement
•
Need to build AV section further
ESTABLISHED CREDIBILITY AND GOODWILL OF MANY
ORGANISATIONS
01.
• EASY TO OPERATIONALISE PLANS
• PLATFORM FOR RAISING ISSUES EXIST
02.
OPPORTUNITY TO GROW, REALISE ONES DREAMS,
IF INITIATIVE
IMPROVE SKILLS, SPREAD WINGS.
TAKEN PEER SUPPORT IS PROVIDED
03.
SPACE TO EXPLORE NEW AREAS OF WORK
AVAILABLE POTENTIAL TO BUILD FURTHER IN MANY
AREAS
04.
OPENNESS TO CONTINUE WORK WITH INDIAN AND
ALTERNATIVE SYSTEMS OF MEDICINE
05.
OF
PROFESSIONALS
WORKING
GENERATIONS
TOGETHER IN COORDINATION - BRIDGING THE
GENERATION GAP
06.
DEVELOPMENT OF EXPERTISE IN ALL MEMBERS OF
THE TEAM
07.
SCOPE FOR ENHANCING GROWTH OF THE LIBRARY
AND DOCUMENTATION UNIT
ALSO
•
With decentralization, opportunity to create greater awareness towards
community health among policy and decision makers
•
Greater participation in improving health policy - states and country
•
Blend of Eastern - Western approaches / philosophies
•
Can develop into a Public Health / Community Health Institute or Centre
I
01.
DIFFICULTY IN GETTING SECOND LINE LEADERSHIP,
WITH SECURITY NEEDS OVERSHADOWING
CREATIVITY NEEDS
02.
POSSIBLE DANGER OF EMPHASIZING THAT OUR
APPROACH IS THE BEST APPROACH
03.
CONTINUANCE OF CHC DEPENDENT ON INDIVIDUALS
04.
FLEXIBILITY OF WORKING CONDITIONS EXPLOITED
EVEN BY FULL TIME AND PART TIME STAFF
05.
INADEQUATE CLARITY IN DELINEATION OF
RESPONSIBILITY AND AUTHORITY
06.
TENDENCY OF TEAM MEMBERS TO MOVE AWAY AND
LEAVE THE TEAM
07.
LACK OF JOB SECURITY
08.
LACK OF OPENNESS TO CHC WORK WITHIN THE
STAFF - CONTROLS NOT DETERMINED BY STAFF
ALSO
•
Financial sustainability still low
•
Dependence factor in our culture
•
Tradition of flexi-management often used by team members to make personal
needs to overshadow CHC needs
•
Too much individualism. Reduced space for others to think. All good things can
be misused
Weaknesses
strengths
1998
Opportunities
Threats
[ 1998
CHC REVIEW MEETING
3rd/4th April, 1998
CRITIQUES / REFLECTIONS / SUGGESTIONS
(Please note down any positive or negative comments, questions, suggestions that you
have after the presentations on 3rd April and after reading the 14 year overview report.
Time will be provided for the reviewers and others as well to share these on 4th April Session V : 9.30 a.m. to 12.30 noon)
i.
2.
3.
4.
5.
Date :
Weaknesses
strengths
1998
Opportunities
Threats
1998
STRENGTHS
\____________________________
01.
LIBRARY AND DOCUMENTATION UNIT
02.
GOOD NETWORK OF CONTACTS (AT ALL LEVELS) AND
STRONG CREDIBILITY WITH THEM
03.
WILLINGNESS
TO
RESPOND
TO
NEEDS
INDIVIDUALS / NGO / GOVT (AT ALL LEVELS)
04.
ATTRACTS PEOPLE ORIENTED TOWARDS A PARADIGM
SHIFTED / OPEN TO NEW IDEAS
05.
INTERACTIVE WITH INCREASING NUMBER OF MULTI
DISCIPLINARY PROFESSIONALS
06.
NON HEIRARCHICAL TEAM WORK (DEMOCRATIC /
PARTICIPATORY)
07.
SCOPE / SPACE FOR INDIVIDUALS CREATIVE GROWTH
(FLEXIBILITY)
08.
KNOWLEDGEABLE
/
EXPERIENCED
APPROACHABLE SENIORS
09.
FINANCIAL TRANSPARENCY
MANIPULATED
/
HUMANE
ACCOUNTS
ALSO
•
Responsive to emerging concerns
•
perspectives based on Indian Experience
•
Promotion of Baloonist approach / Equity / Empowerment
•
Secular; total freedom in work; Planning well
OF
NOT
MOP
SB
01.
SHORTAGE OF TECHNICAL PERSONNEL / SECOND
LINE TEAM
02.
EXCESSIVE BURDEN / WORK LOAD AND CHANCES OF
BURN OUT ON FEW TEAM MEMBERS
03.
PROBLEM OF TIME MANAGEMENT BECAUSE OF OPEN
ENDED CATALYST APPROACH (“MORE THAN WE CAN
CHEW”)
04.
TOO MUCH CATALYST ROLE MAY MAKE
UNWILLING TO TAKE ON RESPONSIBILITY FULLY
05.
NOT EXPLORING ON ALL RESPONSES / IDEAS
EVOLVING
FROM
PARTICIPATORY
ACTIVITIES
(CONCENTRATION ON TRAINING AND POLICY ONLY)
06.
LIBRARY POLICY IMPLEMENTATION
LOAN POLICY NOT STRONG
07.
PRESSURE ON TEAM DUE TO
• SHORT NOTICE / REQUEST
• LAST MINUTE WORK LOADS
• LACK OF FOCUS ON WORK
08.
SELF RELIANCE IN FINANCES / HUMAN RESOURCES NOT ENOUGH EFFORTS AS YET
ESPECIALLY
ALSO
Conflicts between humaneness and professional functioning
Individual roles overlap
Excess flexibility / freedom leading to anarchy / non achievement
Need to build AV section further
US
ESTABLISHED CREDIBILITY AND GOODWILL OF MANY
ORGANISATIONS
01.
• EASY TO OPERATIONALISE PLANS
• PLATFORM FOR RAISING ISSUES EXIST
02.
OPPORTUNITY TO GROW, REALISE ONES DREAMS,
IF INITIATIVE
IMPROVE SKILLS, SPREAD WINGS.
TAKEN PEER SUPPORT IS PROVIDED
03.
SPACE TO EXPLORE NEW AREAS OF WORK
AVAILABLE POTENTIAL TO BUILD FURTHER IN MANY
AREAS
04.
OPENNESS TO CONTINUE WORK WITH INDIAN AND
ALTERNATIVE SYSTEMS OF MEDICINE
05.
OF
PROFESSIONALS
WORKING
GENERATIONS
TOGETHER IN COORDINATION - BRIDGING THE
GENERATION GAP
06.
DEVELOPMENT OF EXPERTISE IN ALL MEMBERS OF
THE TEAM
07.
SCOPE FOR ENHANCING GROWTH OF THE LIBRARY
AND DOCUMENTATION UNIT
ALSO
•
With decentralization, opportunity to create greater awareness towards
community health among policy and decision makers
•
Greater participation in improving health policy - states and country
•
Blend of Eastern - Western approaches / philosophies
•
Can develop into a Public Health / Community Health Institute or Centre
01.
DIFFICULTY IN GETTING SECOND LINE LEADERSHIP,
WITH SECURITY NEEDS OVERSHADOWING
CREATIVITY NEEDS
02.
POSSIBLE DANGER OF EMPHASIZING THAT OUR
APPROACH IS THE BEST APPROACH
03.
CONTINUANCE OF CHC DEPENDENT ON INDIVIDUALS
04.
FLEXIBILITY OF WORKING CONDITIONS EXPLOITED
EVEN BY FULL TIME AND PART TIME STAFF
05.
INADEQUATE CLARITY IN DELINEATION OF
RESPONSIBILITY AND AUTHORITY
06.
TENDENCY OF TEAM MEMBERS TO MOVE AWAY AND
LEAVE THE TEAM
07.
LACK OF JOB SECURITY
08.
LACK OF OPENNESS TO CHC WORK WITHIN THE
STAFF - CONTROLS NOT DETERMINED BY STAFF
ALSO
•
Financial sustainability still low
•
Dependence factor in our culture
•
Tradition of flexi-management often used by team members to make personal
needs to overshadow CHC needs
•
Too much individualism. Reduced space Tor others to think. All good things can
be misused
Weaknesses
strengths
1998
Opportunities
Threats
1998 ]
Fjrj
FjFj
JJ
HEALTH FOR ALI;
Indian Council Of Social Sciences
Research &
Indian Council Of Medical Research.
(1981)
■ Reduce:
7 poverty,
/ inequality and
/ spread education
Q Organise poor and
underprivileged to :
/ fight for their basic rights
■ Move away from :
/ Counter-productive and
/ Consumerist
Western Model of Health
Care
■ Replace with
JJ
P
j Alternative based in the
community.
J1
ES
Dr. Ravi Narayan, Community Health Cell
>41
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Weaknesses
strengths
1998
Opportunities
Threats
[ 1998 J
V
-<
RATIONAL THERAPEUTICS
AND
DRUG
POLICY ISSUES
HOW IT STARTED
- MFC FACLITATED THE MEETING “PEOPLE ORIENTED DRUG POLICY”
♦ ESC
- DR. ZAFARULLA CHOUDHARY GONOSHASTRA KENDRA,
BANGLADESH,
DEC, 1983
♦
CHC
♦ MFC - SUPPORTED AIDAN - KAR_ IATAKA CHAPTER - CHC
DAF-K FORMED
♦
CHC - INSTITUTIONAL PART OF DAF-K; DR. VB PRESIDENT
■i
WHY CHC IS INTERESTED?
X
4
.5
CONVICTION - DRUGS AND PRESCRIBING MAJOR COMPONENT OF HEALTH CARE T ALL LEVELS
•
FORMS A BASIS / STARTING POINT FOR SOCIAL ANALYSIS AND TO
UNDERSTAND THE BROADER
SOCIAL-POLITICAL-ECONOMIC-CULTURAL FACTORS THAT
DETERMINE HEALTH
V'
CHC’S ROLE : PRIMARILY CATALYTICAL
•
RESOURCE PERSONNEL FOR VARIOUS COURSES [eg. DHCA, SJMC]
•
PRODUCTION OF BACKGROUND MATERIAL - AV AIDS, POSTERS ETC.
•
RESOURCE CENTRE FOR ARTICLES / OTHER MATERIAL [JOURNALISTS /
OTHERS]
CONDUCT RATIONAL DRUG WORKSHOPS / SEMINARS FOR:
- PG MEDICAL STUDENTS - CME’S
- DOCTORS
- NURSES
- NGO’S - VHAI, CHAI ETC.,
HEALTH MANAGEMENTSTUDENTS / PERSONNEL
- CONSUMER GROUPS [CREAT ETC.,]
PHARMACISTS
r
INDEPENDENTLY AND IN COLLABORATION WITH AGENCIES LIKE
VHAI, CHAI, CMAI, KRVP, APD ETC.
PUBLICATIONS I
VARIOUS JOURNALS / MAGAZINES
[ > 20; HA, PHY UPDATE ETC.,]
PARTICIPATION AT DIFFERENT OCCASSIONS
POSTER & VIDEO EXHIBITION WITH DAF-K ON OLLE HANSON’S DAY
CONSUMEX FAIR
WORLD HEALTH DAY - PRESENTATIONS
NETWORKING / SOLIDARITY - AIDAN ETC.,
SUPPORTS PUBLIC INTEREST LITIGATION THRO’ DAF-K
MEDIA - AIR AND DD - RECENT FOCUS
OTHER GROUPS / PERSONNEL
BANNED AND BANNABLE DRUGS - NATL LAW SCHOOL
RESEARCH-CURRENT
A
(
[BEING SELF-CRITICAL!
WHAT CHC HAS NOr'
. NE
WORK WITH GOVT.
BUT
- SPT - EDL FOR ICDS PROGRAM
- SPT CMF - EDL FOR KARNATAKA
r
PHARMACEUTICAL COMPANIES - DX
CONCLUSION
•
•
•
FIELD OF RD-WIDE PERSPECTIVE
INTER PLAY OF VARIOUS FACT ORSVITAL INTEREST TO
- HEALTH PERSONNEL
- GOVT. & ITS AGENCIES
- PRIVATE SECTOR - HARMACEUTICAL INDUSTRY
-CONSUMER >
- SOCIAL GRCU
9 o
°
q.
n
ACTION CAN BE TAKEN IMMEDIATELY WITHIN THE SET-UP
CHC’S ROLECATALYTIC
I
LOTS HAS BEEN DONE
LOTS MORE TO DO
/
I
k
CMC
I
DEVELOPMENT
AparnaM. Chintamani
Presentation made at CHC Review Meeting on 3^/4^ April, 1998
Staff Development
CHC has tried to promote capacity building by a process of Staff
Development as part of its management policy.
Staff development :
A process by which the member of the staff is:
Enabled to develop to the fullest potential
Also contributing to the better achievement of the objectives of CHC
This involves:
i) Reflecting together on the objectives and aims of CHC
ii) Giving feedback/suggestions on various policy documents/decisions
approved by Executive Committee of Society.
iii) Giving an opportunity for team members to think about their future
at a personal level as well as in the context of CHC
iv) Providing an ethos where individual motivation and commitment
could be stimulated and brought out.
At CHC, Staff Development is achieved through:
a) Attending short courses/workshops
b) Participating in CHC initiatives
c) Conducting regular staff meetings
d) Continuing Education
e) Organising staff development/staff transformation workshops
f) Introducing incentives for development through schemes such as book
allowance to all staff members.
The above may be further illustrated by the following:
a) Attending short courses/workshops
Encouragement to participate in atleast one short course/workshop
each year
To enhance skill development / Gain orientation in an area
Choice left to team members
Helped by Coordinator/Member-in-Charge who is the “Light that Kindly
Leads”
To cite a few instances :
•
•
•
•
•
•
•
•
•
•
Financial Management conducted by FEDINA/ICRA (MK)
Participatory Programme Planning conducted at CHAI, Secunderabad
(JVJ)
Nature Cure Course conducted by Karnataka Pradesh Prakruthi
Chikitsa Parishad (AS)
Screen printing course (CJ)
Prevention of Drug Abuse & Alcoholism - TTK, Madras (JVJ)
Nature Cure & Yoga (CJ)
Child-to-Child Approach training (SJC/JVJ)
Management of Human Resources (SPT/MK)
Spiritual intensive course (SPT)
Legal Aid Programme (XA)
b) Participating in CHC initiatives
♦ Not dependent on job responsibility or position in team
♦ Within constraints & demands of CHC work, encouragement to
participate in :
*
*
training/orientation sessions
field visits conducted by CHC
An opportunity for introspection is available through:
Staff Enrichment/Staff Transformation Workshops
/ Experimentation with group sessions / activities / journal clubs /
quality circles
/ To build up team consciousness
/ To explore avenues/solutions to work team related problems
There have been workshops on:
Spiritual Health
Job Responsibilities
Communication
Creativity.
On spiritual Health
Balancing intellect and emotions is the essence of spiritual health
db Broadening of vision from ego to altruism.
db Need to tap the altruism part in Community Health.
On job responsibilities
Using R.A.T. - Role Analysis Technique as a tool of self
improvement and job efficiency.
On Communication:
a Listening most difficult part of communication
a Communication is a perception bubble
a Communicating with oneself necessary to break one’s own bubble
a Need to be authentic and true
a Idea to pierce through other persons’ bubble to complete
communication
f) Book allowance
A more recent incentive has been the granting of book allowance to all
team members for their growth and development
■»
Attending:
*
*
Malaria Workshop in Kolar, Bangarpet (CJ)
Workshop on “Hospital Waste Management at Victoria Hospital
(CJ/AC)
Jan Swasthya Rakshak Scheme evaluation meeting {CJ/MS/JA}
Community Health Training programme in Montfort College (AC)
c) Conducting Regular Staff Meetings
0 Weekly/monthly/bimonthly staff meetings
A means to catch up with workshops/programmes/evaluations
attended / undertaken
w- A means to catch up with events on the anvil
0 Adhoc meetings organised around areas of interest
(like meeting a special guest/visitor or on specific topics )
□ Presentation of findings of the CMAI-CSCD evaluation at AGBM (SPT)
□ A meeting with Dr. Gill Walt, Social Scientist, LSHTM, Dr. Thelma
Narayan’s PhD guide, during her visit to India.
w
d) Continuing Education
t
Formal training courses on short-term basis
Study leave as benefit 8s incentive
♦ Masters course in Library Sciences (SJ)
♦ MS Windows & Operating System (VNNR)
♦ Diploma in PC Applications (AMC)
e) Staff Development Workshops
«
A time to lock back and forwards:
Reflection on all aspects of CHC work {both individual & collective}
using a SWOT analysis framework
Extent of success in the implementation of previous years’ Plan of
Action
Annual planning meetings where Plans of Action for the year are
discussed
As a process of staff development, there is scope to move:
upwards: to higher levels of responsibility
sidewards: to alternative job responsibilities
outwards: to take on job responsibilities with one of our
partners/associates in line with individual’s skill and
capabilities
In conclusion^ Staff Development enables members :
y to understand and find participation in own area of work;
to learn about and share skills / attitudes / knowledge needed to
enhance team ethos; and
to participate and foster participation in all activities of CHC,
voluntarily
The above is a birds’ eye view of the CHC Staff Development Process.
c
•>
^Jan's preset
p
u
L
I
c
A
OF
MEDICAL
I
0
N
s
SYSTEMS
Of Trainers (CHAI- Herbal Medicine)
TRAINING
Intermediatory personnel (CHW ayusha)
Grassroot level workers (T.b.a. Myrada)
STUDY GROUP
KARNATAKA HEALTH POLICY
NETWORKING
CHAI NATIONAL CONSULTATION
LSPSS MEMBER
COMPENDIUM OF ADDRESSES
ACCUPRESSURE CHART
CONTRIBUTION
ACCUPRESSURE MANUAL
BIBLIOGRAPHY ON A.S.M.
SJMC UNDERGRADUATES &
POST GRADUATES
AWARENESS
> PVOH SCHEME - SJMC
THREAD - Siddarth Village
ALUMNI ASSOCIATION PHYSICIANS - SJMC
[EDUCATIONAL STRATEGIES
• Planning of Colloquim for CM Dept. - SJMC CHW Course
• Designing one year Diploma Course in
Holistic Counselling, Montfort College
• London School of Hygiene and Tropical
Medicine - 4 days short course to M.Sc., CH
course
• Design herbal medicine course for CHAI
RESEARCH
♦ Exploration of role of Tibetan
Medicine in Tibetal Settlement in
Karnataka
♦ Study group for use of Traditional
Medicine in Bronchial Asthama with
Rastrothana Parishat
• Philosophical integration of various
systems of medicine
• Homeopathy and Community Health
Care including policy analysis
KARNATAKA HOMEOPATHIC MEDICAL
COLLEGE
>
SOUTH INDIA REGIONAL CONFERENCE
- Disability and A.S.M.
ACTION AID PROJECT , Jagalur
SOLIDARITY
► RORES, Srinivasapura
VHAK Workshop - Role of NGO’s in Strengthening
I.S..M.
VHAI - PEER GROUP SUPPORT - TSM UNIT
* ALL INDIA HOMEOPATHIC CONFERENCE
1
Staff To Develop
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DISCUSSION NOTE
A REVIEW OF THE RESEARCH WORK OF THE
COMMUNITY HEALTH CELL (CHC) 1985-1993 *
(Functional Unit of the Society for Community health Awareness, Research and
Action since April 1991)
CONTENTS
1. Brief History
2. Why the Review
3. Framework of review
4. Overview of CHC objectives pertaining to research
5. Points arising from review of research activities of CHC
6. Strengths and weaknesses
7. The dimension of unexpected effects
8. Exploring indicators, outcomes and impact
9. Perspectives for the future
10. Appendix I : Historical review of CHC objectives pertaining to research
Appendix II : Research efforts of CHC from 1984 to 1993 - a chronological
listing
1) BRIEF HISTORY
CHC was started in January 1984. The initial team consisted of four persons.
Of these, two were earlier academic staff members of a department of Community
Medicine in a medical college, and had research interests. During its first phase
(January 1984 - July 19880, CHC was a study-reflection-action experiment.
Early project proposals referred to it as the Documentation and Research (D & R)
Cell. During this period, there was an intense involvement: with health and
development groups in the voluntary sector; with national level groups like
VHAI, CHAI, CMAI; and with numerous individuals.
Organisational
responsibility for the 'medico friend circle’ was undertaken simultaneously. This
included initiation, involvement and support of community based, epidemiological
research among people affected by the Bhopal gas disaster.
In 1986-87, the team took a break for a year during which a research approach
was used to write up an overview of the involvements of CHC. An understanding of
the dynamics of community health action was articulated. Based on this overview,
broad principles of a community health approach in India were arrived at.
* Thelma Narayan, member incharge, Research & Evaluation, CHC
chc/msword/off/resrev.doc
A reflection regarding the future thrusts of the Cell was also undertaken. During this
period, one of the team members did a Masters in Epidemiology as part of the staff
development process to strengthen the research dimensions of the Cell.
Following a review of the approach and work of CHC in June 1990, the Society for
Community Health Awareness, Research and Action was registered with CHC as its
functional unit. Subsequently, the team strength grew to twelve members. Broad
areas of work in support of community health action included * training and information service, * participatory reflections, * networking,
* research and evaluation, * and documentation/library service.
Besides strengthening of earlier initiatives, newer areas were developed. These
grew in response to an analysis of earlier involvements and a perception of needs in
the field. It also reflected the interests and perspectives of different team members.
In research, we moved to initiating and undertaking the prime responsibility for
studies in areas of our interest, in addition to supporting and participating in studies
initiated by other groups.
2.
WHY THIS REVIEW
Team discussions during a Staff Development Workshop (1992/ and in
subsequent meetings, had raised the idea of taking an objective look at our own
work on an ongoing basis. This review is a first step in applying a critical eye to
the research work of CHC. It is also an appropriate and opportune time, since we
have completed a decade since the initiation of CHC. Jt could also help in
developing a longer term perspective and a broad framework or policy for further
developments in research within CHC.
Having completed two major health policy related studies and several other
smaller research efforts, we also feel the need to review our efforts in the area of
research as part of the overall objectives and functioning of the Society.
3
A FRAMEWORK FOR THE REVIEW
•
The written objectives of CHC have been taken as statements of intent as being
accepted by the team and its wise counsel in the initial years, and by the Executive
Committee of the Registered Society since 1991. |ince planning in the early years
was done on a yearly/two yearly basis, several statements are available as part of
project proposals. These have been reviewed, especially those pertaining to
research.
•
Annual reports, reviews and other reports indicate the activities/involvements of
CHC. In this report, the review focus is on the research dimensions of the work.
chc/msword/off/resrcv.doc
•
•
•
Publications, reports, background papers written for various meetings etc., have
been taken as important indicators of the outcome of the various research
involvements.
Presentations and participation in meetings at which contributions based on the
research findings were made or discussed, have also been taken as indicators of
outcome.
Impact is much more difficult to assess in the case of research. This could be
taken up for discussion.
Some learnings from the experience of research, being carried out in the ethos of
the voluntary health sector have been identified.
4
OVERVIEW OF CHC OBJECTIVES PERTAINING TO RESEARCH
During the years 1984-1990, CHC was a small, informal, unregistered group,
linked to the Centre for Non-Formal and Continuing Education, Bangalore.
Funding and therefore planning was done on a yearly/two yearly basis. It was an
'experiment’ and the objectives emphasized the research dimension (see Appendix
I for details).
Moving beyond public health and community medicine, the desire of the initial
team was to study the real life dynamics and praxis of community health action.
With the growing realization at a national level that existing methods were
inadequate to meet the health needs of a majority of people, particularly the poor,
alternative approaches towards improved health and health care in the 1970’s.
We too had experience of experimenting with alternatives in health care
approaches and in training during the earlier medical college phase. The initiation
of CHC was to provide an opportunity for full time, closer interaction and study
with this very alive and dynamic process.
We felt the need to study and develop a deeper understanding of:
*
*
the health care situation - by the Governmental, voluntary and traditional
health sectors,
underlying principles of the alternative approaches being tried.
Application of the spirit and method of enquiry was necessary for this.
Existing methods of medical and health practice research, of which we had
some knowledge, were inadequate. We therefore used what we called the
“open-ended approach”. That we were exploring and learning about different
methods of health and social research is evident from the usage of different
terms in the objectives during that short period chronologically. These were:
chc/nisword/off/rcsrcv.doc
Documentation and Research,
Study - Action - Reflection,
Socio-epidemiological Research,
Participatory Research,
Action Research,
Health Practice Research,
Community Health Research,
Health Policy Research.
We moved in our objectives from “understanding the philosophical
assumptions, goals, and methodologies of the ongoing, experiential process”
to “focusing on the enabling - empowering dimensions of health action”
to “using health policy research to influence or help bring about relevant
changes in health policy”
'Research in Community Health Policy Issues’ is presently the stated research
objectives of the Society.
With registration of the Society, it is important to note that the objectives of
the Society were widened to provide for the development of training
strategies, the strengthening of the documentation and library services, etc.
5. POINTS ARISING FROM REVIEW OF RESEARCH ACTIVITIES OF
TIC
Appendix II lists out the research involvement’s of TIC during the decade.
The two or three main researchers have had the support of research officers,
assistants, investigators, and of the office team. Some general points based on the
experience gained are being raised. They will need consideration when planning
for the future.
5.1 Evolving appropriate methodologies
Standard methods of medical research (as we know them) were not sufficient
to 'study
the dynamics of community action’ which was our initial area of
interest, health work by the voluntary sector and health issues were essentially
social processes in the community and needed to be studied as such. The
methodology used therefore was “an informal discussion technique with the
researchers participating with health action initiators in a common reflective
exploration of their past experiences as well as their ongoing and future action
plans”. These were supplemented by several informal personal communications,
field visits and group discussions.
chc/msword/off/rcsrcv.doc
The formal approach was not used. There were no research protocols, pretested
questionnaires, formal interviews or statistical analysis of data.
As we began to more clearly recognize the paradigm shift in thinking from a
disease-medical - providing process to a health-social-enabling process, we too,
as researchers were being transformed. At moments we were totally involved
with issues such as the aftermath of the Bhopal disaster, tuberculosis, or the need
to build a movement towards a more rational drug policy.
However,
documentation of events, experiences, reactions, responses, etc., was maintained,
it was only later that a sabbatical break provided the opportunity to digest and
analyse retrospectively the experience. This led to an articulation of certain
principles of community health action and components of the paradigm shift in
health. This was shared with other groups and individuals in order to get a peer
review /critique, at fora in India and abroad, through meetings as well as through
circulation of reports and publications.
5.2 The need for further training in research methodology was felt as we got
involved with several health related issues, particularly the Bhopal disaster
aftermath and the effects of pollution to the Tungabhadra river by Harihar
Polyfibres. Training certainly provided a sound base, underscored the need for
rigour, objectivity, sound data collection, tools for analysis and hopefully an open
questioning mind.
The process of learning needs to be an ongoing one as we use research
methodology to address different areas of study.
Looking to the future, there is probably scope for expansion into a multi
disciplinary research team.
5.3 The experience with two strategies of research interventions have been
interesting. These were a) support to studies initiated and conducted by other
groups b) undertaking studies ourselves.
We extended the concept of 'catalyst role’ to research by supporting the research
work of other voluntary groups. There were eight such involvements (4.1, 4.2,
4.3, 4.4, 4.5, 8, 11, 12 in Appendix II). The time taken for these inputs ranged
from a few days to few months of full time involvement. There were a few
requests that did not proceed beyond preliminary discussions and are therefore
not listed. We discovered that :
*
Voluntary groups in the field often do not realize the implications of
research/study viz.,
- of the need for objectivity;
- of the need for rigour, standardization, etc;
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- of the need for careful data collection;
- of the requirements for time and resources;
- factors such as bias and confounding variables are seen as being irrelevant
academic issues;
- of being open to find that one’s assumptions may not always be right.
There are therefore differences
frustration on both sides.
in expectations which could be a source of
*
Follow-up on a study project may stop at any stage, sometimes even just after
planning. Here too, levels of satisfaction are low.
*
Even if taken to completion, reports may lie unutilised. We may be unable to
utilise them for advocacy or other purposes as they are 'classified documents’ and
not our property.
*
The areas that we are called to work on are not necessarily in our prime areas of
interest. In the process, given the limitation of time, we may then not be able to
work adequately on areas of deep interest to us.
After this experience we feel that being of support to the research/studies
undertaken by other groups could be an additional involvement, while our “prime
time” could be in the area of interest/priority of CHC and of the concerned
researchers. Thus the support role could get lower priority.
The longer term research involvements (eg. understanding community health
action, medical education, CHAI study, & Bhopal study), while demanding
sustained interest, patience, and much 'shoe-leather’ work -were deeply
satisfying.
It is evident from the listing in Appendix II that the output in terms of
publications, reports, presentations and interactive meetings has been fairly
substantial from these studies. It provides us a very good base for continued
involvement from these studies in these areas. There is a concurrence between
analytical and emotional interest which provides enough energy to go through
periods of overwork and stress that sometimes occur.
Therefore for each major area of research work taken up by CHC, there must be
atleast one key person to whom it means a lot, and who can sustain the study
process to completion.
Creative Tensions : As the team grew, with a greater variety of areas of interest,
and with increasing amounts of work in the different areas, there sometimes
developed creative tensions between and within people. There was need for
greater communication in an understandable way between the difference areas of
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interest. The demands of open ended catalyst functioning with an open door and
often open house policy competed with the demands for consistency, time
schedules and the technical and organizational needs of the research studies.
Disciplining of oneself and organisation of one’s time was not always easy. It is
hard to keep away from the attractions of interesting meetings and assignments
when one is committed to completing a long term research project. Perhaps time
for such involvements should be built into the planning cycle.
Demands of the research study like mass mailing, organising meetings,
cyclostyling and printing also put pressures on all staff especially as some of these
were time bound activities. Facing up with the quantitative dimensions of
research work as also its long desk based periods also needed adjusting to.
This experience draws attention to the need for adequate staff strength and
infrastructure to reduce strains. The possibility of separating research from the
other functions or vice versa needs to be avoided, so as to enhance the richness of
work. However while no compartmentalization is necessary - commitment to
research work for substantial part of one’s time may be required for research
staff.
6
STRENGTHS AND WEAKNESSES
6.1 We start with weaknesses and limitations so as to end on a positive note.
a) Personnel
Involvement in several types of work simultaneously cause delays and if excessive
affects the concentration required for the job at hand.
Change of research assistants requires an orientation process each time. It would
therefore be better to build a small core team and take on investigators, data entry
operators, etc., on a project basis.
b) Infrastructure
Lack of computers, and of word processing and computing skills at the time of
the major studies was a problem. There has been a subsequent build up of such
capacity. However this infrastructure as well as secretarial and staff time is being
used for all other CHC needs as well. This causes delay and inability to get
reports out, carry out maintenance procedures, etc.
Adequate seurctaiial
assistances and infrastructure (computer, software packages, typewriters, storage
space) will have to be planned for. The secretary of the research unit would be
somewhat different from the office section and this could be seen as a
specialisation opportunity.
chc/msword/off/rcsrcv.doc
I
c)
Planning and Management of time and other resources
The CHAI study was initiated rather late, when we already had commitments to
the medical education project, as well as work required during the early phase of
registration of the Society. Since the CHAI study was time bound to a Jubilee
and rather extensive in scope, there was some strain on the team and on the
system. Expectations and objectives of studies need to be based on realistic
planning of all aspects including time and human resources.
d) Clarity of roles
There is some ambiguity within us, and hence also with the groups we deal with
as partners in research, regarding our roles. We have swung between being
researchers, trainers, planners, and resource persons.
While this is very
interesting, it does adversely affect the quality of the research work.
6.2 Strengths
e) The wise counsel and executive committee as well as the leadership of CHC
promoted and supported the research dimensions of the work.
f) The flexibility of the Cell allowed us the freedom to undertake wide ranging
studies, build linkages, modify timings, etc.
g) Our previous linkages with national networks like CMAl, CHAI, mfc, VHAI
provided support including peer support. This was particularly needed since we
were not based in an institution or linked to a University.
h) The commitment of CHC team members made it possible to undertake the
workload required for the studies.
i) The technical quality of the studies has been appreciated by senior professionals
and others. However, this is a matter for others to judge.
4. THE DIMENSION OF UNEXPECTED EFFECTS
a) One of the greatest benefits was the tremendous learning and personal growth
that resulted from involvement in the research studies.
b) Peop!° who have participated as investigator, panclHs and respondents also
mention this dimension of learning and growth, even as contributors to the
studies.
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c) There are a few groups and individuals working in areas unconnected to the
studies who have commented that the reports are useful to their thinking and
work.
1
EXPLORING
RESEARCH
INDICATORS,
OUTCOMES
AND
IMPACT
OF
This is an area on which we need to brainstorm with others.
Study or project reports, publications, and related meetings, conferences,
discussions and peer reviews are one aspect. Appendices I & II list these out for
the studies undertaken by CHC.
To look for outcome and impact for instance in the case of medical education,
one would need to have a long term perspective. It would be difficult also to
make a cause effect link between the study and any changes taking place, since
there are several other factors promoting and hindering change.
The CMAI study provided information about the distribution and type of work
undertaken by the membership as well as critical feedback from them regarding
the functioning of CMAI. Changes in the Constitution have been made and a
Plan of Action drawn up. An understanding of the membership could be used for
better designing of training programmes and other strategies of support. Here
again a linear relationship between changes taking places and the study cannot be
drawn with several factors and personalities playing a role. Unintended effects
are also occurring, with discussion generated on many issues.
2. PERSPECTIVES FOR THE FUTURE
Focus of Research
9.1 Need to focus our areas of research on selected health policy issues, for a
period of time (5 years) and review the situation once more.
9.2 Continue research in the area of medical education and education for health
sciences.
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9.3 Other areas in health policy that could be taken up are:
* decentralisation of health policy and health care (initiated as part of doctoral
programme);
* role of the voluntary sector and Government-Voluntary sector interlinkages
(initiated);
* health financing.
9.4 New researchers could develop their own areas of interest and skill.
Team Development
9.5 A multi-disciplinary team could be considered in the long term, possibly
covering the areas of bio-statistics, sociology, anthropology, and possibly political
science, economics, besides health service research, epidemiology and health
policy research.
9.6 Other skills needed are computing and data management, documentation and
library basics, office management, editing and publishing. While much of this
could be from the common CHC pool, there would be need for one/two full
timers.
Infrastructural Development
9.7 Build up of library in the area of research methodology,
reports and journals.
research study
9.8 Computer and software packages
9.9 Typewriter, storage space and room - as part of CHC pool.
9.10 Since there is a possibility of shifting the CHC office, the present building
may be retained for the research unit.
Finance
9.11 We could consider the possibility of applying to ICSSR, ICMR, DST and
CAP ART for research grants. International donor agencies supporting research
could also be contacted eg TPRC, SID'V, besides partners who hav-* already
supported us.
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Other
9.12 For peer group support, there is a need to build up and strengthen linkages
with research groups and individuals in Bangalore. Also with institutes of
Advanced Studies in India and with research groups in the voluntary sector eg.
FRCH, CINI, SEARCH Gadchiroli.
3. CONCLUSION
This is draft discussion note. We would value your comments particularly on
strengths and weaknesses and on perspectives for the future.
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APPENDIX I
HISTORICAL REVIEW OF CHC OBJECTIVES PERTAINING TO
RESEARCH
When the initial team members left the medical college, the stated need was to set
up an informal, small, Documentation and Research (D & R) Cell, to encourage
and catalyse the growing awareness and interest in Community Health and Health
by the People’ (1). This was to “provide a sound information base for voluntary
health effort”.
Objectives included the study of:
a) Government health policy documents,
b) health statements of major groups in the voluntary sector, and
c) existing evaluation studies in the voluntary sector. It was also planned to
study:
i) health care projects,
training courses for health care personnel,
health components of curriculum of formal/non-formal educational
programmes in the governmental/voluntary sector.
ii) people’s perceptions of community health programmes,
iii) perception by community health project personnel of coordinating
agencies/training institutions.
Special focus was to be given to Karnataka.
The primary thrust of CHC in its early years was therefore on documentation and
research. This was undertaken by involvement and reflection with several groups
working in (or interested in) community health in the field. By the understanding
and insights ('findings’) gained through this “study-action-reflection” process of
enquiry (“research”)_ it was hoped to contribute to the emerging peoples’ health
movement especially through evolving relevant training and support strategies
that could be put into action by local institutions or state level/central units of
national organisations’.
During the first two and a halt years (January lVd4 - Juiy 1980) the focus was on
'understanding the dynamics of community health action’ and getting an overall
perspective of the situation in Karnataka, evolved as an unwritten objective. To
this was also added the organisational responsibilities for the medico friend
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circle (mfc) which resulted in a research involvement in the aftermath of the
Bhopal disaster.
A review after two years (in 1986) brought out the need to write up the CHC
experience in an analytical way, so that the major learnings could be shared with
others. This also resulted in a note on 'an approach to the future’.
Besides Networking, Documentation and Communication, an important need
identified was 'to support ongoing health initiatives with relevant and quality
socio-epidemiological research with an inter-disciplinary field oriented team that
could promote wider appreciation of socio-epidemiological perspectives in
problem solving in health and health care by a participatory research team plan to
focus their efforts in the future. Participation in networking, documentation and
communication efforts will remain an important but secondary goal”.
“The main objective was to gradually interact with all the groups involved in
/community Health Action in Karnataka, including individuals, health project
teams, network, 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
orientation”, 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”.
It was envisaged that two types of research interventions could be organised, viz.,
a) Research to support ongoing health work done at the request of health
projects;
b) Research initiated by the team itself as long term funded projects in areas of its
own interests or of its individual team members. This would also offer
opportunity to evolve methodological alternatives in response to varying field
situations.
Both approaches were considered are necessary to maintain viability of a research
team whose overall goal would be to support the ongoing community health
process.
A subsequent action plan for the period October 1987 - December 1988 mentions
the “crucial but unmet need for action-research (primarily socio-epidemiological
and health practice nriented) to support on-going health prelects and the p,v°lvinp
issue based health movements in the State”.
chc/msword/off/rcsrcv.doc
Early discussions in 1988-89 regarding the formal registration of a body evolving
out of the earlier CHC, spoke of a “registered community health research
society”.
The plan of action for 1989 mentions the “evolution towards an Action Research
Cell supported by a network of individuals and initiatives, committed to
promoting community health action”. Focus of action research on the enabling empowering dimensions of health action was thought of
In 1988, the importance of health policy research was recognised as a means to
influence or help to bring about relevant changes in health care policy. This was
seen as a support to and a logical extension of the enabling/empowering process
with communities. The needs of staff undertaking policy research assignments to
be free of other CHC responsibilities for periods of time was expressed, to allow
for completion of research work. Early experience also suggested that it would
take a little time for the voluntary health and development sector to sustain the
rigorous methodology that community health research would entail.
The team expanded to eight persons at this stage. Team reflections in 1990 raised
the option of registering a Trust/Society and to “build up over the years a more
distinctive image, moving beyond the philosophy of “catalyst action” to a more
specific research focus. Different team members also identified their own areas of
interest and priority areas for focus for work. These ranged from health issues of
urban slum dwellers, personnel management, medical pluralism, child health, and
open-ended catalyst work to policy research.
A five year review meeting in June 1990 indicated that registration as a Society
was necessary to maintain autonomy and flexibility. Supportive community health
work was to continue,” while at the same time developing a sharper policy
research focus in its work”.
The Society for Community Health Awareness, Research and Action was
registered in April 1991. The objective pertaining research (out of six objectives)
reads as follows:
“To undertake research in Community Health Policy issues,
particularly:
- community health care systems;
- health human power training strategies;
- health and development interactions; and
- medical pluralism and integration of medical systems.
Ref: 1) Proposal ror a Documen'afon & Research Cel! fO
R cel!)
in Community Health, 28th August, 1983.
2) Community Health Cell - an approach to the future.
3) Community Health - The Search for an Alternative Process, CHC,
1987-88 (Red Report).
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APPENDIX II
RESEARCH EFFORTS OF CHC FROM 1984 TO 1993
- A CHRONOLOGICAL LISTING
Phase I January 1984 - September 1987
1.0 Involvement in and report of the study - reflection - action experiment
with community health and development groups
(June 1984 - June 1986)
1 ■ 1 Community Health - The Search for an Alternative Process, (red and
brown mimeo reports, 1987-88, pp 100 & 32 respectively)
1.2 Community Health in India, (cover story) Health Action, July 1989 Vol
12, No. 7.
1.3 Community Health - The Quest for an Alternative Narayan R., Social
Action, Vol. 35, No. 3, July - September 1985, Indian Social Institute,
New Delhi.
1.4 Community Health - The Quest for an Alternative Narayan R., in
Development with People’ Ed. Walter Fernandez, Indian Social
Institute, New Delhi (1985).
1.5 Towards a Paradigm Shift in Health Narayan R., Link, Vol. 7, No. 2,
August - September 1988. (Newsletter of Asian Community Health
Action Network).
1 6 Towards a People-Oriented Alternative Health Care System - Narayan
R., Social Action, Vol. 39. July - September 1989.
1.7 Presentation at the Indian Peoples’ Science Congress, Bangalore, 1989.
1.8 Concepts used as a basis for presentations sharing with groups in India
and abroad (UK, Germany, Canada). Also used in CHC’s training and
research efforts.
2.0 Initiation and support to community based epidemiological research by
the medico friend circle, following the Bhonal gas disaster.
2.1 Several reviews & papers (mimeo), articles in m.f.c. bulletins, mfc
publication of full & summary report of study
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2.2 The health impact of the Bhopal disaster - an epidemiological
perspective’ (Narayan T., dissertation for the Masters in
Epidemiology at LSHTM, London University, September 1987).
Later published in Economic and Political Weekly, August 18 and
25, 1990.
2.3 Presentation at Second National Convention on Bhopal, New Delhi,
April 1991.
2.4 Submission on Health Effects of Industrial Hazards to the International
Permanent Peoples’ Tribunal, Narayan T, October 1992.
2.5 Submission on the health status and health care of victims of the Bhopal
gas disaster of 1984, Submission to International Medical Commission
on Bhopal, Narayan T., January 1994.
3.0 “An approach to the study of health aspects of environmental pollution
caused by a viscose rayon factory” Narayan T., m.f.c., mimeo, July 1985.
4.0 Support / guidance to surveys and workshops :
4.1 Support to community survey among adivasis in Mysore district
(Dr. Mahesh)
4.2 Survey of Government health facilities in Tumkur district (Jyothi and
Raj) '
4.3 Short term studies on use/misuse of drugs in small hospitals and health
centres (Dr. G.D. Ravindran)
4.4 Study of the training of village health workers in OXFAM funded
health projects (Vanaja Ramprasad)
4.5 Participatory evaluation of community health projects organised by
Indian Social Institute, New Delhi (Preliminary Planning).
4.6 Seminar on Research Priorities in Occupational Health organised by the
Regional Occupational Health Centre, Bangalore, National Institute of
Occupational Health, Ahmedabad & Indian Council of Medical
Research
5.0 Health and Agricultural Linkages
5.1 Health, Nutrition and Agricultural Development - A Bibliography
(August 1987) - Narayan R., sabbatical assignment, London School of
chc/msword/off/resrev.doc
Hygiene and Tropical Medicine, London.
5.2 Health, Nutrition and Agricultural Development - an overview of the
situation in Karnataka. (August 1987) - Narayan R, sabbatical
assignment, London School of Hygiene and Tropical Medicine,
London.
5.3 Epidemiological Patterns associated with Agricultural Activities
in the Tropics (paper co-authored by Narayan .R., with Professor
David J. Bradley, Ross Institute, London) for joint WHO/FAO/UNEP
Panel of Experts on Environmental Management for Vector Control :
meeting in Rome, September 1987. (Effects of Agricultural Develop
ment on Vector Borne Disease, FAO Monograph Agl/Misc/12/87).
5.4 The Tea Garden as a Research Eco-System, paper co-authored by
Narayan R. with Professor David J. Bradley, Ross Institute, London
and Dr. V. Rahmathullah, UPAS I, India, 1987 (In Capacity for Work
in the Tropics - Ed. Collins & Roberts, Cambridge University, 1988).
Phase II 1988 - 1989
8.0 Participated in the planning of an 'Evaluation of the National TB Control
programme’ with ICORCI (March 1988). Report - 'An indepth study of the
National TB Control Programme’ by ICORCI, for Government of India,
sponsored by WHO.
9.0 Health Status of the people of Karnataka in the context of the health situation in
India, Narayan T., background paper for FEVORD-K, Annual Meeting, May
1990.
10.0 Evaluation of the Community Health Development Programme of Kottar Social
Service Society, 1990.
11.0 Support to analysis of a study by the medico friend circle on the reproductive
outcome of women exposed to toxic gases during Bhopal disaster.
12,0 Support to study on diarrhoea related morbidity among children.
chc/msword/off/rcsrev.doc
Phase III 1990 - 1993
13.0 Medical Education Project, sponsored by the Christian Medical Association of
India (CMAI) and the Catholic Hospital Association of India (CHAI) viz.,
STRATEGIES FOR GREATER COMMUNITY ORIENTATION AND
SOCIAL RELEVANCE OF MEDICAL EDUCATION IN INDIA’.
This included a multi pronged research strategy, viz.,
* a review of Expert Committee recommendations,
* a review of medical college experiments/innovations,
* feedback on major aspects of undergraduate medical education from
medical education from medical graduates with peripheral health
institution experience, and
* a review of experience of community health trainers in the voluntary
sector.
The methodology comprised a literature review, correspondence with medical
colleges and community health training groups, field visits and discussions with
medical college faculty and interns, interviews, questionnaire to medical graduates, a
dialogue (2 day meeting) with community health trainers. A medical educators
review meeting was organised in June 192 for presentation and review of findings.
Reports/Publications/Meeting arising thereof:
Publications
13.1 Narayan R., Narayan T., Tekur S.P.,
Strategies for Social Relevance & Community Orientation of
Medical Education - Building on Indian Experience.
Bangalore, CHC, March 1993, pp 74.
13.2 Narayan T., Narayan R.,
Evolving Medical Curriculum from Graduate Feedback based on
experience in Peripheral Health Institutions
Bangalore, CHC, March 1993, pp 74.
13.3 Narayan R.
Stimulus for change : An Annotated Bibliography
Bangalore, CHC, August 1993, pp 48.
chc/nisword/off/resrcv.doc
13.4 Narayan T.
Training Doctors for India
Health Action, June 1991, Vol. IV, No. 6
13.5 Narayan T. & Narayan R.
Evolving a Curriculum framework through research of Indian
Praxis
Trends in Medical Education, First issued, August 1994 (in press)
Reports / Papers / Presentations
13.6 Preliminary Communications of (13.1) and (13.2) in mimeograph
form presented at the XXXI Annual Meeting of the Indian Assn,
for the Advancement of Medical Education, Bombay, 1992.
13.7 Towards an alternative medical education - Step by Step ( An
Anthology of CHC papers and initiatives), December 1992.
13.8 Community Health Trainers Dialogue,
On an Educational Policy for Health Sciences
October 1991, Bangalore, CHC, 1992, pp. 103.
13.9 Narayan R. (ed).
Proceedings of the Medical Educators Review Meeting,
June 1992, Towards a Collective Commitment
Bangalore, CHC, December 1993, pp. 152
13.10 H.J. Mehta Memorial Oration at St. John’s Medical College:
Rebuilding The Foundations : Reexamining Preclinical Medical
Education, Narayan R., December 1991.
13.11 Presentation at meeting of Indian Association of Physiologists and
Pharmacologists, December 1991.
13.12 Summary papers of 13.1 & 13.2, along with posters presented at
August 1993 bi-annual General Meeting of the International Net
work of Community Oriented Educational Institutions for Health
Sciences at Sherbrooks, Canada, at the Conference on Student
Centred Education.
13.13 Paper on Public I-Jonltb Training in the T hrlergraduat^ Modical
Curriculum was also presented at the above meeting.
chc/insword/off/rcsrev.doc
Presentations of findings were also made.
13.14 to different groups of staff and students at Medical Medical Centre,
and
13.15 to faculty of the government Miraj Medical College.
14 0 THE GOLDEN JUBILEE EVALUATION STUDY OF THE CATHOLIC
HOSPITAL ASSOCIATION OF INDIA (1991 - 1993)
A miltipronged research strategy was employed. Key aspects included :
0
a detailed study of 20% of the membership (discussions with a sample of
health institutions across India by trained investigators using a semi structured interview schedule)
0
Mailed Questionnaire to the remaining 80% of CHAI membership
0
Structured feedback from members of the Executive board,
representatives of Regional units, and Staff members of CHAI.
0
Financial Review, and the
0
Policy Delphi Method of Research
Publications / Reports / Meetings arising thereof are given below :
Publications
14.1 Narayan T., Jacob J., Philip T.
Seeking the Signs of the Times
Secunderabad, CHAI, October 1992, pp. 64.
14.2 CHAI Study team
Major problems faced by CHAI member institutions in their
medical / health work.
Are national / regional collective solutions possible ?
Secunderabad, CHAI, February 1993, pp. 10.
14.3 Veliath A.
A Golden Harvest - New Horizons
Secunderabad, CHAI, November 1993, pp. 112
(Abridged, adapted revision of study reports)
chc/nisword/off/rcsrev.doc
14.4 Francis C.M. (Ed)
Towards Life in its Fullness : Action Plan arising from the CHAI
Golden Jubilee Evaluation Study.
Secunderabad, CHAI, March 1994, pp. 43.
Reports
14.5 Narayan T., Jacob J.
Two Thousand AD and Beyond : Contextual & Policy level issues
important for the future health related work of CHAI
Findings from the Policy Delphi Method of Research
Bangalore, CHC, March 1993, pp. 64.
14.6 Narayan T., Philip T., Jacob J.
At the Fiftieth Milestone - Evaluative Feedback from members
concerning the Catholic Hospital Association of India.
Bangalore, CHC. June 1993, pp. 132.
14.7 Narayan T.
Report of the feedback from Staff Members of CHAI,
March 1993, pp. 39.
14.8 Srinivasan P.
Report on Financial Management of CHAI, March 1993, pp. 39
14.9 Narayan T.
Report on Feedback from members of the Executive Board &
Regional Unit Representatives
14.10 Narayan T.
Report prepared for the first meeting of Sister Doctors
14.11 Narayan T.
Report from Delphi Research on 'The role of voluntary organisations
in health care services’ prepared for National Meeting of Community
Health Trainers organised by CHAI.
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Meetings arising thereof
14.12 Eleven regional meetings
14.13 Nine professionals/special interest group meetings
14.14 49th General Body Meeting of CHAI at Guntur, A.P (Nov. 1992)
14.15 50th General Body Meeting of CHAI at Secunderabad, A.P.
(Study team members facilitated/made presentations at the above
meetings)
14.16 Others :
Several core group meetings to arrive at the Plan of Action
Presentation to CEBEMO/Misereor at Oeestgeest, Netherlands.
Presentation to Students/Faculty of COADY Institute, Canada.
15.0 Narayan T.
'Research issues in Decentralised Health Care’.
Paper presented at National Workshop on Health Policy in the context of
Decentralisation, organised by the National Institute of Advanced Studies,
September 1990.
16.0 Evaluation of'Reaching the Unreached’ project,
Madurai, 1992, (Dr. Shirdi Prasad Tekur & Dr. V. Benjamin)
17.0 Evaluation of CMAI, Child Survival Programmes
(Dr. Shirdi Prasad Tekur)
18.0 External Evaluation of Indian Social Institute
- Training Centre, Bangalore,
Report by R. Katticaran, Thelma Narayan, and S. Raghuram, September 1992
19.0 Evaluation of Madhya Pradesh - Voluntary Health Association
Dr. Shirdi Prasad Tekur, 1993.
20.0 Paper on Conceptual Framework for Assessing Women’s Health Needs (Thelma Narayan), background paper for a national workshop organised bv
Child in Need institute, Calcutta, later printed in m.f.c. bulletin, August December 1993 as background for the 1993 m.f.c. Annual Meet on
Reproductive Health.
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21.0 Narayan T., participated in brain storming meetings concerning research on
following issues :
OCoronary Heart Diseases at SJMCH with Dr. Salim Yusuf
(National Institute of Health, USA), Dr. Prem Pais and Dr. Ranga
Nayak.
0 Pre & post assessment of health education aspects of water and
sanitation projects with Dr. Ramakrishna, International Union for
Health Education.
0 Reasons for stagnant status of IMR in Karnataka (Epidemiology cell of
SJMC)
0 Risk factors for cancer cervix with Dr. Sudhir Krishna of Bangalore
unit of Tata Institute of Fundamental Research
22.0 Support to study of drug prescription patterns (Dr. Shirdi Prasad Tekur).
23.0 Developing a baseline questionnaire for a development project, ROKES,
Srinivasapura (Dr. Shirdi Prasad Tekur).
(*tn/ac/msword/ c:\off\ resrev.doc/pp. 24/May, the 13th, 1997)
clic/msword/off/resrcv.doc
Organisational Reviews of
SOCHARA-1998
i
The Fifteenth Mihestone . .
A BIRD'S-EYE REVIEW of COMMUNITY HEALTH GET.I,
JANUARY 19&4
DECEMBER 1997-
Distributed at the CHC REVIEW MEETING - held on 3rd & 4th April
1998 at
The Brothers of Holy Cross, 47, St.Mark’s Road, Bangalore - 560 001.
Community Health Cell
Society for Community Health Awareness. Research and Action
No.367, ‘Srinivasa Nilaya’ Jakkasandra I Main, I Block, Koramansala, Bangalore - 560 034.
Phone : (080) : 553 15 18; & 552 53 72
I
Fax : (080) 55 330 64 (Mark: Attn - CHC)
I
CONTENT LIST
SI.
No.
Particulars
Pages
A.
B.
C.
D.
E.
F.
G.
H.
Introduction
The beginning (or the Roots....)
CHC Experimental Phase I - 1984 - 86
The mfc Phase (April 1984 - March 1986)
The CHC team training break (1986-87)
The Red Report -1987
CHC Experimental Phase II (1987-89)
The June 1990 Review (The end of the experiment..)
The Registration of SO CHARA (1990-91)
Creating Awareness of the Community Health Paradigm
Social / Community model of Health
Promoting Rational Drug Campaign
Towards an integrated view of medical systems
Undertaking Research in Community Health
Key research initiatives
Evolving Educational Strategies
Alternate Community Health Training Sector
Field level training - focussing on the grassroots
Community Health courses for young seminarians/trainees
The Alternate Medical College
Community Orientation of ‘Mainstream’ efforts / requests
Dialogue with Health Planners
Voluntary Health Sector
Government Health Sector
Promoting/Supporting community health action
The CHC Library & Documentation Unit
The CHC Web of interaction (the matrix of the CH network)
Peer group support - recognising the paradigm shift in
individuals
Participatory Ethos in Management (trying to practice what we
preach)
Networking and Solidarity
Building collectivity in local/state/national efforts in health
CHC Society Phase II (1993-96) - new directions
1
2
2
I.
J.
K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.
U.
V.
w.
X.
Y.
Z.
4
5
6
6
7
8
9
12
14
16
18
19
19
21
22
23
24
25
CHC Consolidation (1994-96)
26
CHC’s initiatives in South-North & South-South dialogue
The challenge of mainstreaming
CHC Communications /publications
WHAT NEXT - on the edge of a metamorphosis______________
27
28
29
30
^Cfie Fifteenth tMzCestone . . . .
A bird’s-eye review of CHC from January 1984 to December 1997.
A. Introduction
1. The Community Health Cell (CHC), the functional unit of the Society for Community
Health, Awareness Research and Action, began its fifteenth year in January 1998.
Over the last fourteen years, it has grown from a small, informal team of four persons
working from a small, single room office in the front room of a private residence, to a
team of 14-15 people supported by network of around 40 CHC professional associates
based in a small centre, which apart from group offices for-the staff, has a well
organised library and documentation unit and a training/seminar room with a wide
range of teaching/learning aids. The centre is also governed by an autonomous
registered Society with specific aims and objectives.
2. During these years, the CHC has gone through various growth phases; identified
various functions to support community health action through non-governmental and
governmental partners; explored various aspects and issues relevant to Community
Health action; promoted networking on various issues and actively participated in
emerging networks in the country; evolved educational and research strategies in
community health; and initiated dialogue with health planners and decision makers to
enable the formulation and implementation of community oriented health policies.
3. On 3 rd and 4th of April, the CHC team has organised a 2 day review exercise which will
focus on all the important aspects of CHC’s activities, both technical and managerial;
share the CHC team’s own SWOT analysis (Strengths, weaknesses, opportunities,
threats) of the Centre’s functioning and organisation; share some future scenario
building exercises conducted by CHC initiatives; and explore ideas and suggestions by
all its Society members and a group of reviewers and associates, invited specifically for
the purpose. The event is a serious reflection on the past, present and future. It is also
a celebration, of reaching an important milestone, when with a small core group of
invitees, from a large network of associates, friends and contacts, CHC wishes to
record its appreciation for the solidarity, the fellowship, the interactive, participatory
peer group support it has received all these years.
4. This short reflection will highlight some facts, some initiatives, some concern and
some perspectives that will provide useful background information to the reviewers
and participants of the exercise. It is neither comprehensive nor a complete report but outlines the key and salient features of CHC’s 14 year history - that has been
marked by opportunity, and challenge.
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5. This note is supplemented by short reflection/review of our research; our Field
training; our management; a publication list and 6 newsletters that have been sent out
since we registered CHC as a Society in June 1990.
B. The beginning (or the Roots
)
6. CHC was established in January 1984 when the two co-initiators of CHC moved
beyond the Department of Community Medicine, Department of St. John’s Medical
College after completing nearly a decade, as teachers/field trainers. During this
decade, they had been involved in the development of six rural field practice areas in
Sidlaghatta, Hesarghatta and Dommasandra talukas around Bangalore with an
enthusiastic, field oriented, multi disciplinary team under the guidance of visionary
leadership and senior public health peers (An interesting feature of the CHC
experiment has been that even today in 1998 - most of that initial group at St. John’s
are linked in one way or another to CHC’s ongoing initiatives).
7. Apart form bringing to CHC, interactive field experience from field training of medical
students, interns, nurses, community health workers and plantation medical officers,
the co-initiators also had established links with Indian Social Institute, Bangalore, the
SEARCH experiment in Bangalore; national coordinating agencies like VHAI, CHAI
and CMAI; and were members of the medico friend circle.
8. A year of extensive travel to community based projects in the States of Karnataka,
Tamilnadu, Gujarat, Maharashtra, Haryana, Orissa and West Bengal - visiting
CHWs/Doctors trained at St. John’s and a wide spectrum of mfc core group and
innovative health and development projects was also a key inspirational experience in
1982.
9. The decade of community oriented training experience at St. John’s (!974-83) and the
involvement with VHAI, mfc, ISL SEARCH, CHAI as resource persons and or
participant during this phase and the 'balloonist perspectives’ acquired from an intense
grassroots contact during the 'Bharat Darshan’ of 1982 could be regarded as a
foundational experience, on which the CHC framework and process was built.
10. Between 1982 and 1983, the co-initiators had extensive discussions with a wide range
of contacts, peers and inspirational resource persons at various levels. The broad
parameters that emerged from all these interactions was the need for a Cell / Centre
that:
i) focussed, studied and built on the wealth of Indian grass roots experience, that
was still marginal to the efforts of most formal training and research institutions.
ch c/msword/c:/office/l 5stone, doc
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ii) Provide information and advisory support in an interactive, participatory and
responsive way to the increasing number (especially since the early 1970s) of
community health action initiators in the voluntary sector in India.
iii) Facilitate the coining together of health action initiators to network, learn from
each others experiences and build collective linkages and action thrusts.
iv) Move ‘Health’ beyond its severe bio-medical orientation and professional control
by the medical profession and facilitate the emergence of Health and Health action
as an agenda of groups outside the medical system.
11. These perspectives required moving beyond a medical college base and evolving a
small centre whose ethos and function and milieu would allow the development of
an alternative paradigm in health care - a new set of ideas and concepts that would
endorse and sustain community health action at the grassroots and simultaneously
challenge the ‘bio-medically’ constrained mainstream system and institutions to be
more community oriented and socially relevant.
In retrospect, the evolution of CHC was as much a proactive experiment of
evolving a new paradigm, as it was a symbolic protest against the constraints and
limitations of a predominantly bio-medical and technomanagerial approach to
health and health care, represented by the medical colleges of the early 1980s.
C. CHC EXPERIMENTAL PHASE - 1: 1984 - 1986
12. CHC was initiated as a study reflection action experiment in Bangalore in January
1984. It was established as an informal resource Ceil supportive of ongoing and
evolving community health actions. The experiment started with a small group of
four (RN, TN, KG, KC), of whom three had moved beyond a department of
Community Medicine of a Medical College. Since it was an experiment, the Cell
was a health project supported initially by the STAND trust and later the Centre
for Non Formal and Continuing Education-Kamataka, both educational trusts
supporting informal education initiatives focused on the marginalised especially in
rural / tribal areas. The framework of support negotiated with these trusts allowed
a creative autonomy and a participatory form of governance supported by a 3
member team of Senior Peers (CD, CMF & GJ).
13. The main objectives of the Cell were:
i) to support community health action by voluntary agencies
ii) to provide a sound information base for voluntary health effort
iii) to encourage groups
- to recognise the broader dimensions of health
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to see health as a process of awareness building and organisation among
people
to a greater sharing among field workers and activists to build an
understanding of‘process’ rather than ‘project’ in health action
to see health efforts as part of a broad based movements free of labels.
iv) to create closer links between groups so that these efforts become part of a
health awareness building process leading to a ‘peoples’ health movement’
For objectives (i) - (iv) the Cell initially planned to relate particularly to groups in
Karnataka, focussing specially on the needs- of the underprivileged. As the months
passed, however this focus was not easy to maintain because within a year or two
requests for support began to come in from a larger geographical region - South
India and beyond.
14. During the first 30 months of our involvement, we were able to deepen our
understanding of the dynamics of community health action in India and also get an
overall perspective of the situation in Karnataka. During this experimental phase
of 30 months, we perceived phenomenal enthusiasm and experienced a wealth of
learning from all those we worked with and a deep sense of confidence and
satisfaction began to develop in the CHC team:
a confidence that the moving beyond the ‘medical college base’ had not been in
vain
a satisfaction that we were beginning to respond and provide support to an
urgent but greatly unmet need.
The whole experiment was proving to be a two way mutually supportive process with the CHC team not only providing support but also learning and enriching its
own perspectives in the process.
D. The mfc phase (April 1984 • March 1996)
15. Very early in the experiment, the Cell also accepted, for two years (1984-86), the
organisational and bulletin responsibilities of the Medico friend circle - a national
network of doctors and health activists interested in making health services and
medical education more relevant to the needs of the large majority of the people in
India - the poor and the underprivileged. The mfc experience was a very rich
learning experience - because while our focus was on South India, it provided us
an opportunity and challenge to support a national network of health activists and
action initiators.
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16. The mfc phase which overlapped with the first two years of CHC’s evolution had
some highlights
*
Facilitation of the mfc interactive dialogue on TB and Society (Bangalore);
examining Medical Education {Hoshangabad}; Environment and Health
{Khandala}; Revitalising mfc {Patiala}
*
Active participation in the Rational Drug campaign of mfc and in the evolution of
the All India Drug Action Network - a national network of health and development
agencies, science groups, academic departments, regional networks, trade unions
and others promoting rational drug policy perspective.
*
Organisation and supportive facilitation of mfc’s Bhopal disaster related initiatives
which included a socio-epidemiological study; a communication strategy to
support the ngo health network in Bhopal and informing the affected people of
issues and findings of the study.
*
Publication of mfc bulletins from 101 to 120 and occasional rational drug
newsletters - and conversion for this phase of the bulletin from being just a vehicle
of debate/discussion on issues, to becoming a vehicle of enhancing collectivity in
action and effort.
E. The CHC TEAM Training Break (1986 - 87)
17. After the first 30 months, three members of the CHC’s four member team,
identified a need to equip themselves further with certain skills that would enhance
our abilities to support the emerging requests from Community health action
initiators. A one year break in the process was operationalised and three CHC
team members spent a year undergoing training in:
i. Epidemiology (TN)
ii. Personnel management (KG)
iii. Low cost communication (KC)
The fourth member of the team - the coordinator of the earlier phase (RN) spent a
considerable part of the year evolving CHC’s first Report on Community Health the search for a process which was later circulated to all our partners and
associates and many friends in the ‘community health movement’ inviting their
reaction and comments (see next para). He also spent a sabbatical year doing a
short focussed project on linkages between Agriculture, Health and Nutrition
which resulted in an approach paper on aEpidemiological patterns associated
with agricultural activity in the tropics with special reference to vector-borne
diseases'”as part of a FAO/UNEPAVHO document.
chc/msword/c.’/office/l 5stone.doc
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18. During this year, RN also got an opportunity because of the year in UK to give
guest lectures at various training and resource institutions in UK - e.g. the London
and Liverpool Schools of Tropical Medicine & Hygiene; the Institute of Child
Health, London; AHRTAG - London; Oxfam - Oxford; and other centres.
Perspectives on the Axioms of Community Health - derived from our experience
were shared with students doing Community Health/Public Health postgraduate
courses - (From various parts of the developing world) and well received.
F. The ‘Red Report’ - 1987
19. A Report entitled Community Health: The Search for an Alternative Process which
was a report on the study-reflection-action experiment by CHC, Bangalore from
January 1984 - June 1986 - was the first major documentation effort - that was
circulated to a wide network of Community Health enthusiasts and action initiators
in India - for comments, suggestions and an invitation for interactive dialogue.
The Red Report (as it was called because of a bright Red cover) included a
situation analysis of Health care in India; methodological overview of the CHC
teams process of reflection; a reflection on Community Health in India; a note on
the Movement dimension; an outline on the Tasks for the future; and a reflection
on the evolving dimensions of the Community Health approach. The report also
listed out all the groups, initiatives, individuals we were in touch with; the key
meetings; a reading list and additional reference and a list of materials generated by
CHC in the first phase.
The report was well received, and many who read it sent us comments. It also
helped CHC be accepted by a large group of innovators and action initiators in
India - as a serious group attempting to build on the collectivity of Indian
experience - a reputation which continues till today.
G. CHC Experimental Phase 11(1987 - 89)
20. On regrouping at the end of the training phase, the team functioned from a rented
accommodation centrally located in Bangalore where facilities for office, library
and a room for meetings and discussions was available. Apart from the four
original team members from experimental phase I, the team was joined by two part
time members (SPT, MK.) who greatly enhanced the scope and outreach of the
work. Additional team members also joined to support the work of CHC (MSN,
VNNR, RU, SS) (see Appendix)
21. Building on the first phase, the CHC team now concentrated on certain new
thrusts after the training phase. These included:
chc/msyvord/c:/office/l5stone.doc
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i.
Building up our documentation cell and getting more organised for easy
access/referencing
ii. Networking with persons involved with community health action and
involving them in various initiatives or responses of the cell
iii. Exploring areas of research with NGOs mainly in a supportive role.
iv. Preliminary exploration of management issues with some voluntary sector
projects
V.
Training programmes in Community Health - both formal and informal based on participatory and interactive approach.
vi. Continuation of the involvement in the campaign for Rational Drug policy
and Rational Drug Use
vii. Development of a study group on Traditional Systems of Medicine and
some additional initiatives towards the exploration of integration of
Systems of Medicine.
viii. Some training and research initiatives focussing on health in urban slums
ix. Continuing the peer support work which involved reflections and
exploration of options whith individuals seeking greater relevance in health
and development related work.
H. The June 1990 Review - (The end of the experiment
)
22. In 1990, six years after in its inception, CHC was reviewed by a team of resource
persons specially invited together for the task in June 1990 (included DKS, MI,
VS, MJ, PK). A report entitled the CHC Experiment (1984-89) was presented to
the group through short poster sessions/OHPs.
The areas covered were
Community Health Cell - An overview (TN); Networking and Formal and Informal
Training (MK); Rational Therapeutics and Drug Policy issues and Integration of
Traditional Systems of Health Care (SPT); Managerial and team building process
(KG); a SWOT analysis (RN) and Looking to the future (CHC team).
23. The report arose from a series of internal reflections in the CHC team, to identify
and clarify individual goals and to explore group goals as well beyond the end of
the experiment (December 1989). The experience of the years 1984-89 was
reviewed critically to understand various dimensions and learning experiences from
the experiment. The team reflection and the June 1990 review lead to three
important conclusions about the next phase of CHC.
*
The overall consensus was that the experiment had been
innovative/interesting/effective enough to lead to the establishment of a
more long term identity made possible by registering an autonomous
trust/Society with the objective of continuing the promotion of community
health action and research.
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*
In terms of focus, while open ended catalyst technical support role with the
growing voluntary health sector had been enriching and had greatly helped
to build CHC’s evolving credibility, a need was felt to allow team
members, particularly fulltimers to initiate more focussed research (action
or policy oriented) primarily under their control to enhance the long term
commitment and their own work satisfaction.
*
Policy Research emerged as an important priority area because this seemed
a major lacunae in voluntary sector effort in the beginning of the 90s.
There was need to take a reflective overview of the diversity of experience
and the wealth of innovations/altematives/options that have emerged in the
voluntary health sector at the 1 micro’ level and evolve large macro policy
guidelines that can strengthen the Social Relevance thrust of evolving
health policies.
*
While efforts to register a Society was initiated in the post review phase
CHC team members began to plan to focus on three areas that had key
policy implications
a) Community oriented/Social Relevance in Medical Education
b) Medical Pluralism and Child Health
c) Community Health in Urban Slum.
L The Registration of SOCHARA (1990-91)
24. After the post experiment transitional phase, CHC metamorphosed from an
autonomous, little Cell, linked to the Centre for Non Formal Education and
Continuing Education, Ashirvad, to a fully registered autonomous Society for
Community Health Awareness, Research and Action. Since the team had become
widely known as the. CHC team, the Community Health Cell (CHC) continued to
remain as the name of the functional unit of the Society. The informal team
coordinator of the experimental phase (RN) became the Secretary/Coordinator of
the Society; the three member wise council of the experimental phase (CMF, CD,
GJ), the key resource persons in the team (TN, SPT, MK, KG); and many
members of the June 1990 review committee, all became members of the
Registered Society (DKS, MI, VS, PK, MJ); The registered Society and CHC
moved to an independent, rented accommodation in Jakkasandra, Koramangala,
where CHC continues to be presently situated. Some team members moved on to
newer assignments (MK, KG). Newer ones joined (MK, XA, SJC RM CJ
HNV).
25. The key component functional initiatives of the experimental phase became the six
objectives of the registered Society.
The metamorphosis was carefully
operationalised so that all the salient features of the ethos, framework and
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traditions of the experimental phase were internalised into the formation of the
Society without letting the legal requirements; the minimum but unavoidable
institutionalisation; and the increasing structural definitiveness, from obscuring
what the review process had identified as the essential core strengths of the CHC
experiment, which were:
-
its essentially interactive, participatory, catalyst linkage with the diversity of
evolving Indian experience
its commitment to participatory management
its commitment to enhancing the empowerment dimension of health action.
26. The Objectives of SOCHARA were:
*
To create an awareness in the principles and practice of Community
Health among all people involved and interested in Health and related
sectors.
*
To undertake research in Community Health
particularly:
0
0
0
Policy
issues
Community health care strategies
Health human power training strategies
Integration of medical/health systems
*
To evolve educational strategies that will enhance the knowledge, skill
and attitudes of people involved in Community Health and development.
*
To dialogue with health planners, decision makers and administrators to
enable the formulation and implementation of community oriented health
policies.
*
To promote and support community health action through voluntary as
well as governmental initiatives.
*
To establish a library and documentation centre in Community Health.
In the paras that follow, we shall look at each of these dimensions and objectives of
CHC’s work.
J. Creating Awareness of the Community Health Paradigm
27. The Social / Community model of Health
Since CHC’s evolution was symbolised, by a moving beyond a ‘bio-medical’
institution base (even though it was a base already undergoing a social/community
reorientation) - the development of the concept of a paradigm shift from
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Biomedical model to a social/community model was a natural evolution. The
evolution of the concept was inspired by atleast two other events:
i.
the mfc debate on Health Care which way to go - which tried to find a way
forward between the inactive cynicism of those who believed that
sociopolitical change had to take place before health care could change and
the unrealistic euphoria of the alternative health care approach initiators of
the 1970s and early 1980s who saw community based health workers and
appropriate technology as the answer to all our problems.
ii. A very serious reflection initiative with the CHAI - Community Health
Department in May 1983, which brought together the key thinkers of
VHAI, CMAI, ISI, SEARCH and others to help, the now famous vision of
CHAI - which defined community health as a process beyond community
medicine.
Community Health
is a process of enabling people,
to exercise collectively their responsibility to their own health,
and
to demand health as their right
.
Building on the above definition but going far beyond the Red report identified
many components/axioms of community health, which were brought together as
‘The Community Health Approach’. It was in the 1989 - special issue of
community health of Health Action however that the concept of the Paradigm Shift
was first enunciated. The idea of this ‘concept’ was to go beyond the ideological
debate of capitalist/socialist view of health which was common among radical
health thinkers and activists in the country and to identify changes and focus of
efforts on new approaches/ideas that constituted a new interconnected group of
ideas - a new paradigm! And a shift from current mainstream thinking! It was also
an attempt to provide a more simple, inspirational framework to help action
initiators understand shifts that were needed at various levels components of action
to stimulate further experimentation and also to endorse emerging ideas that were
already becoming action initiatives all over the country.
The ‘paradigm shift’ concept may have been seen as being rather simplistic at the
time of its evolution - but as time went its ability to stimulate/inspire/endorse the
evolving experiments become obvious.
ch c/msword/c:/office/l 5stone, doc 10
The concept of the shift in paradigm then began to be used by CHC in many of its
further explorations and soon the issues covered by the concept begin to increase
(a more detailed presentation of this concept is part of the Review).
In short, the shift was from medicine to health; from patients as beneficiaries, to
people to participants; from providing to enabling and empowering; from
intracellular research to baloonist research; from professional control to
demystification; from individual focus to collective/community focus and so on.
The shift has now been evolved as tables for management, training, disease control
etc., as further adaptations to the idea.
28. Promoting Rational Drug Campaign
CHC’s role in the area of Rational Therapy and Drug Policy issues has been
catalytic in the initial phase and complementary to Drug Action Forum-Kamataka,
in the later years.
CHC contributed to the evolution of AIDAN both through its double role (mfc &
CHC) in the later 1980s. In later years, its efforts and initiatives in Bangalore
helped in the development of DAF-K, and since then CHC team members have
contributed constantly to DAF-K management and action initiatives.
CHC’s role has been primarily that of a documentation and clearing house for
RDU / RDP / RDT 'information; technical support to workshops for different
sectors; CME for doctors and postgraduates, and support to health education
efforts in the Rational Drug Campaign (posters, slides, etc.)
It may seem surprising that so much effort has been spent by a team interested in
Community Health - on the issues of Rational Therapeutics and Rational Drug
Policy. This is however not ‘accidental’. It is our firm conviction that ‘drugs and
prescribing’ from a major component of health care at all levels and are an
important part of the expectations of the lay consumers and general public. Since
most professionals and health care action initiators have some knowledge in this
area, we have found it a good starting point for social analysis and to understand
the broader social-political-economic-cultural faction that determine drug
availability, affordability, accessibility, use and misuse in society. It is a relatively
non-threatening field and of equal interest to health professional and consumers. It
is also an area in which some action can be immediately undertaken within a health
care organisation. In addition, it also greatly helps the appreciation of the ‘new
paradigm’.
29. Towards an Integrated view of Medical Systems
A major component of the new paradigm of thinking promoted by CHC
particularly through the initiatives of SPT have been the attempts at the integration
ch c/msword/c:/office/l 5stone, doc 11
of Medical Systems. The Allopathic dominance that pervades health and medical
care systems needs to be countered by a more wholistic, dialogue oriented
approach to Indian Systems of Medicine like Yoga, Nature Cure, Ayurveda,
Siddha, Unani, Tibetan Medicine and to alternative systems of medicine like
Homeopathy and Acupuncture.
The focus of efforts have been centred around demystifying these systems and
making skills such as herbal remedies / folk remedies and acupressure part of
peoples and community based health workers skills. So they have formed an
important component of all our training programme.
Attempts have been made to increase openness to these systems among medical
students, doctors and voluntary agencies. Special training programmes organised
by CHAI, AYUSHA and VHAI/VHAK have been supported and some years ago,
a study group of practitioners from different systems was organised for a while to
evolve this process further in a collective way.
More recently, team members have been exploring integration through more
interactive research approaches and qualitative methods of enquiry.
Solidarity has been shown to efforts of LSPSS, FRLHT and CHAI in this year and
more recently, the initiatives Faith and Healing Ceil of CMAI have been supported
through active participation in collective reflection.
While the community health paradigm has primarily focussed on the shift of
community health action from 'providing package of services’ to
enabling/empowering health action by the community, CHC efforts at promoting
rational drug use at all levels and integration of medical systems have been
complementaiy strategies towards ‘the new paradigm’.
K. UNDERTAKING RESEARCH IN COMMUNITY HEALTH
30. A more detailed Research review will be presented at the CHC review but here,
the key framework and initiatives are highlighted.
CHC’s involvement in research started as part of its catalyst work and researchers
initiating field research were among the various groups of people who sought
CHC’s advise, and support from the earliest phase of the experiment. CHC
believed that if the alternative health care approach and or movement had to move
towards providing quality counter-expertise on behalf of the poor and marginalised
in society, then this counter expertise needed to be based on good research effort;
collection of valid evidence/data; and a serious effort in evolving/addressing policy
issues and imperatives. These ideas/dimensions of work were strongly stimulated
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by CHCs involvement in the mfc/CHC responses to the Bhopal disaster aftermath both in the research and communication strategy responses.
31. Key research initiatives were-.
i.
The study on Community Orientation and Social Relevance in Medical
Education;
ii. Study on building curriculum framework from Graduate Doctor feedback.
iii. The Jubilee Evaluation of CHAI through both questionnaires and structured
interview of member institutions;
iv. The Delphi forecast of Economic, political and social trends that have an
impact on Health; the Health issues and problems emerging from this emerging
scenario and the challenges to the voluntary and Mission sector.
V.
The recently concluded Public Policy Analysis of TB Control in India - based
on semi structured interactive interview with TB patients in H.D. Kote and
Telandur Taluks of Mysore District and complemented by interviews with
community members, local leadership, health care workers, doctors and
decision makers all the way upto the State Health minister.
vi. The Review of the Malaria situation in the country and the Report on
“Towards an appropriate malaria control strategy” that built up through an
interactive process - the identification of issues of concerns and alternatives
for action.
32. The CHC research process was flexible and while building on existing
methodology it tried to innovate and strengthen the peoples perspective; the
field/grassroots perspective; and the community perspective; While building
on a sound foundation of Epidemiology and research methodology, CHC
initiatives in research focussed on interactive, participatory, qualitative
approaches beginning from balloonist situation analysis.
As part of the overall paradigm shift, the research efforts went beyond
reductionist, intracellular, bio-medically focussed efforts of many of the current
mainstream researchers to exploring, balloonist, social, epidemiological
analysis that looked at social, economic, cultural, political, management,
environment and other issues of a broader framework. Hopefully this has
resulted in a deeper understanding of health and health care realities in our
work.
ch c/msword/c.'/office/l 5ston c.doc 13
L. Evolving Educational Strategies
33. The Alternate Community Health Training Sector
From the ven7 inception, the CHC team has been constantly invited to provide
inspirational and technical inputs into various ongoing courses organised by
various institutions, networks and agencies. These have been in the from of
workshop inputs or course inputs and have included INSA, RUHSA, SEARCH,
ISI, SJMC, NIPCCD, CMAI, VHAI, CHAI, VHAK, CHAI-KA, FEVORD-K,
XEME, KIMS, KRVP and so on. All aspects of Community Health have been
covered and also Rational Drug Use, Integration of other Medical Systems and
Health policy issues.
Recognising the significant contribution of the alternative training institutions in
the voluntary sector, CHC tried three times to bring all the CH trainers in the
country to network and work together. These were supported by VHAI, CMAI
and CHAI respectively. While the first dialogue supported by VHAI led to a plan
of action to maintain the information sharing effort and the second dialogue
supported by CMAI/CHAI led to a Statement of Shared concern and evolving
collectively on Educational Policy for Health Sciences; the networking efforts did
not proceed further because of the preoccupation of coordinating agencies with
other initiatives. In the Medical Education Project - this group was studied and
ideas based on their work was collated and incorporated into the new strategies.
This is an area that may have to proceed further with CHC’s proactive and
sustained effort.
34. Field level Training - focussing on the grassroots
While most of the training especially in the initial phases was focussed on the
team/staff members of voluntary sector projects in health and development, a
concerted shift was made particularly from 1993 to focus on grassroots/community
based health workers. A separate review of this aspect of our training efforts is
available as a supplement to this report. This shift was a challenge to CHC since
we moved from English as a primary medium of instruction to a vernacular ethos
where instruction had to move to Kannada, Telugu, Tamil and Malayalam and
often a multilingual effort as well. Under the able and committed leadership of
SPT, this shift was not only possible but it developed phenomenal credibility for
CHC at grassroots level, challenging the CHC team to evolve new methodologies
more relevant to such training (see separate report).
ch c/msyvord/c:/office/l 5ston e.doc
14
35. Communit}' Health Courses for young seminarians/trainees
In the early experimental phase of CHC, a workshop was organised for formaters
from seminaries and training institutions to help catalyse a shift of approach from
the institutional response of earlier Mission related health work to the new
paradigm of community based and oriented approaches. Since St. John’s, CHAJ
and INSA are others were primarily catering to those who had completing training
and then reached the field situation, CHC decided to complement these efforts by
focussing on young seminarians under training. The experiments at Jyothisadan,
Knpalaya, Saccidananda training centres have also been a very good training /
learning experience for CHC team, where the participatory / interactive training
methodology has been developed further. (See next section)
36. The Alternative Medical College project
Building on the mfc anthology CHC initiated a medical college research project
which studied Community Orientation and Social Relevance Strategies in Medical
Education - building on various sectors of experience and experimentation.
During the Medical College Project - the major effort was to evolve a strategy for
Miraj Medical College (an alternative experiment) in collaboration with CHAICMC-Vellore, STMC, CMC-Ludhiana, CHAI and others. When the 4Nliraj
Project’ failed to materialise, the project seemed to have been in vain. However
over the next few years interest in the ideas generated have resurfaced and atleast
three colleges in the region are hoping to develop some linkages with CHC to
explore these ideas and their translate into programme (Pramukhswami Medical
College, Karamsad Gujarat; B.P. Koirala Institute of Health Sciences, Dharam,
Nepal; and G.K. Medical College, Savar, Bangladesh).
More recently, the newly established Rajiv Gandhi Institute of Health Sciences
(RGUHS) in Bangalore has begun to establish a Medical Education Wing and the
CHC team has begun to work closely with the Medical Education Consultant of
RGUHS. Apart from helping to facilitate the first M.B.B.S. course restructuring
workshop, efforts are being made to evolve shorter courses on Rational Drug Use,
Research Methodology for PG students, Involvement in restructuring workshops
for II MBBS and final MBBS are also possible. Reorienting mainstream medical
education by voluntary incrementalism is the new guiding principle for CHC’s
efforts in Medical Education because no serious alternate experiment is a reality as
yet.
37. Community orientation of Mainstream ’ efforts /requests
More recently, the range of training requests have broadened, moving from
voluntary sector training projects to mainstream - academic centres like medical
colleges, nursing colleges, colleges of other systems of medicine, pharmacy
ch c/msword/c:/office/l 5ston e. doc
15
college, homescience and general arts and science colleges, governmental training
institutions including IPP-VIII etc., and so on. This increasing requests from
mainstream colleges is both a sign
<' of CHC’s evolving credibility as well as a very
positive sign that mainstream institutions are increasingly concerned about
social/community issues.
M. Dialogue with Health Planners
38. Voluntary Health Sector
The initial phase of CHC s experiment was focussed on the voluntary health sector
especially in South India and an increasing involvement over the years with
coordinating agencies of the voluntary sector at national level like VHAI, CMAI,
CHAI and at state level - VHAK, CRAEKA, CMAI, WBVHA, MPVHA, APyTLA
FEVORD-K, etc. Dialogue with these health planners/coordinators of the
voluntary sector was an important beginning.
Even though, we were a secular group, CHC recognised early in its development
that the Mission Hospital sector’ which was a large component of the voluntary
sector was in deep ‘vision crisis’. Unable to handle the medical market economy,
it was simultaneously being challenged to more beyond institutional approaches to
community based/oriented options. CHC has played a very significant role in
harnessing this creative crisis and helping coordinaters/policy makers/leaders
develop new visions, community oriented missions and pro-people oriented
policies.
The Mission sector has been a pioneering contributor to the
medical/health care sector in the country and our goal has been that it can became
a pioneer for the newer health care approaches and policies as well.
Some of the contributions of CHC have been
*
Significant contribution to the evolution/clarity of CHAI’s Community
Health vision since the inception of its Community Health Department and
thrust.
*
Facilitating discussion/dialogue on a more People Oriented/rational drug
policy within mission institution, CHAI and CMAI’s involvement in the
larger movement was catalysed by CHC.
*
Participation in the evolution of the CHAI - Health Policy for Member
Institutions (1989).
*
Participation in the evolution of CBCI Health Policy for Church related
Health institutions in 1991.
ch c/msyvord/c:/office/l5ston e.doc 16
*
Helping CHAI and its members to understand the emerging Health
challenges and the responses required (Seeking the signs of the times; and
the Action Plan etc., are well known documents).
*
Stimulating CMAI membership through a provocative 'Health Advocate’
column in their medical journal to seriously consider significant policy
commitment to new challenges.
*
Panicipating in the evolution of the CHAI - AIDS policy, etc.
39. Government Health Sector
Gradually, as our credibility was established we were increasingly called upon to
attend government policy meetings, dialogue or workshops to bring macro
perspectives that built on micro level action. The significant involvement in this
area included:
Involvement in Consultative Committee on Rural Development initiated by
Government of Karnataka at Planning Commission’s request;
Response to Planning Commission initiative on peoples participation in
planning and implementation;
Involvement in the reviews of Primary Health Care System Development in
1990s by GOI and WHO in southern region (Bangalore) and at National
level (Lucknow);
Involvement in various dialogues organised by GOI/GOK on Govt.-NGO
collaboration and linkages;
Response to Perspective Plan for Karnataka (GOK);
Dialogue on Health Section of Sth Plan Document of GOK;
Dialogue of VHAK with GOK - Health Ministry and Directorate;
and involvement with the Report on State of Peoples Health in Karnataka
Involvement in the multicountry dialogue on Govt. - NGO collaboration
organised by World Bank in Indonesia for India, Pakistan, Bangladesh,
Philippines and Indonesia (represented VHAI at this meeting).
Contribution as an Associate to the Independent Health Commission
initiative of VHAI concluded recently.
ch c/rnsword/c:/offi.ce/l 5ston e. doc 17
40. In more recent years CHC involvement in Malaria and TB Control related
initiatives with VHAI and CMAI has resulted in dialogue opportunities with
NMEP and NTCP planners on control related issues and options.
In addition dialogue and interactive reflections organised by NIPCCD, WHO,
Planning Commission, IGNOU and other governmental agencies have quite often
seen active CHC participation. While these opportunities have been good for
presenting CHC’s evolving perspectives they have been somewhat adhoc and need
fairly vigorous and sustained follow up if they need to make a meaningful impact.
CHC has always participated and supported policy evolution/lobbying efforts
through national coordinating agencies. This experience has been very varied with
some nagging questions about goals, process and sustainability of efforts which
will be discussed in the review.
N. Promoting / Supporting Community Health Action.
41. CHC s field training and interactive workshop have increasingly moved towards
supporting community health action. The ‘Intense Field training’ phase 1993-95
were specifically geared to supporting community health action.
Many requests that come from voluntary sector organisations on a day to day basis
is often field action or atleast field event oriented. Due to shortage of staff and
also a realistic, appreciation of the inability to sustain field action due to the
demands of a catalyst function CHC has never taken on a field practice area for
sustained public health/community health action.
42. Should a Resource Support organisation also have its own field practice areas?
This has been an ongoing dilemma and issue for debate! CHC has all along
encouraged younger team members to focus on field action and field related
experiences to develop skill, sensitivity and confidence. This has always been
possible by linkages with our partners without having to administer the RFPA as
one of our responsibilities. This policy has allowed CHC to relate to real life
situations in a number of project areas rather than getting preoccupied by the
demands and distractions of a field practice area totally under ones control. The
pros and cons of this policy have been debated and all along we have decided to
actively support action by voluntary sector projects, government organisation,
health and development activists in a wide variety of areas and sectors, without
getting tied down to action in a defined geographical region. This has also helped
us to root in actual real life situations rather than focus on ‘models’ and ‘ideal field
practice’ areas.
In all our involvement and partnerships, we have tended to discourage the event
oriented, project oriented, adhoc camp type approaches in community health
action and have always tried to enhance the process oriented, people empowering
ch c/m^word/c:/office/l 5ston e.doc
18
long term involvements, so that people/communities benefit from these interactions
and do not get used as guinea pigs for the varying agendas of institutions, projects
and professional initiatives.
O. THE CHC LIBRARY AND DOCUMENTATION UNIT
43. The CHC Library' and Documentation is our prize possession. It reflects the CHC
paradigm shift in its focus and its collections. Grey literature based on action and
experience rather than typical professional literature is our focus. We focus on
reports, bulletins, newsletters, CED documents by post, resource files of papers
and handouts, research reports, field reviews, etc., rather than scientific journals
and texts.
The unit has helped a wide range of users come in contact with the
diversity of Indian experience.
44. The audio visual unit now has posters, pamphlets, slidesets, videos and has been
supponive of all our training programmes and also that of other groups. We have
a very open and flexible loan policy which is being increasingly used by a larger
number of users.
Recently, the Raja Rammohun Roy Trust has agreed to support the library as an
example of a special interest public library.
In keeping with the demands of the information age, CHC is in the process of
computerising the collection and increasing the interactive dimensions of its
collection.
A detailed note on the library and its collection; the library policy; the classification
used; the list of journals and newsletters and a catalogue of the audio visual
teaching aids is available on request.
45. The library owes its development to all our contacts at a national level and friends
and associates who continue to send us materials. A surprising aspect of the
growth has been the continuous inflow of ‘gratis’ material. More recently various
professionals (associates) are contributing their personal collections of materials - a
trend which augurs well for CHC Library. The organisation based on the VH/J
classification is entirely due to the long standing efforts of SJ our earliest CHC
part-timer and later supported by others (NG, JCN, MS).
P. THE CHC WEB OF INTERACTION (The matrix of the CH Network)
46. In the last 14 years, the CHC team has interacted with a rich diversity of people and
groups in Community Health and this matrix/web of interaction is today a major
strength. The people and groups who have been involved from all over the country
include:
chc/msword/c:/ofjice/l 5stone.doc
19
1.
Individuals in search of greater social relevance in Health and Development
work;
11.
Health and development projects in rural and tribal areas and in urban
slums
iii. Health and Development trainers in the voluntary sectors;
iv.
Networking and issue raising groups like mfc, AIDAN, Drug Action
Forum-Kamataka, etc.,
v. Coordinating agencies at Centre and state level like VHAI, CHAI, CMAI,
VHAK, CHAIKA, FEVORD, CSI, ACHAN, etc.
vi. Development projects, networks, training centres like SEARCH, ISI,
ICRA, INSA etc.
vii. Groups working with women, street children , AIDS problem and patients;
leprosy projects; child labour, environmental groups; Human rights groups,
etc., and more recently with peoples movements.
viii. Government officials and planners and resource persons - at Karnataka,
Madhya Pradesh, Rajasthan and National level.
ix. Staff and postgraduates of St. John’s Medical Colleges and other medical
colleges in Karnataka, CMC-Vellore, JIPMER - Pondicherry, and other
colleges.
x. Academics and researchers from a wide variety of background - both
national and state level institutions and governmental, voluntary sector and
private backgrounds.
xi. Health and Development advisers and resource persons and India-desk
offices of a range of funding partners - Oxfam, Misereor, Cebemo (now
Bilance), Memisa, EZE, BFW, DANIDA, SIDA and other agencies mostly
of European origin.
xii. A very wide range of academics/researchers and resource persons from key
resource centres and training centres abroad - especially in UK, USA,
Canada, Norway, Sweden, Germany and more recently since the
involvement in the WHO policy process with resource persons from Africa,
Latin America and South and South East Asia.
chc/msword/c:/office/l5stone, doc 20
xiii.An increasing number of journalists, media persons, teachers, lawyers,
social workers, consumer activists and from other walks of life as well.
Q- PEER GROUP SUPPORT - RECOGNISING THE PARADIGM SHIFT IN
INDIVIDUALS
47. This has probably become one of the most important of CHC’s contributions to
the evolving movement - the provision of peer group support, reflection, review,
interactive dialogue with a very large number of individuals, both young and old,
who at various levels in their career wish to seek an involvement in the voluntary
health sector, and the community health movement or wish to consider changes of
vocation, direction and life experiences. This catalyst work has meant providing
time and space for individuals to share their experiences; their anxieties; their
frustrations; their creative ideas; their fears and their plans. Many CHC team
members have themselves experienced the sorts of crisis that often mark these
shifts, in an individuals paradigm in the context of work or vocation and having
valued all those who supported them at this stage - we have tried to offer the same
to others in solidarity.
Hours have been spent responding to such requests - all times of day - all days of
week and though it has always been quite exhausting and demanding for the core
CHC team, particularly RN/TN/SPT who made this as part of their responsibility,
it has also been worthwhile.
48. Today CHC’s very live, deep and rich linkage with a wide cross section of health
action initiators in the country is partly the outcome of this activity. It is very
heartening to meet, people who have felt this support to have been very useful,
meaningful or significant at the time it was offered. For many, it was a crucial
decision making phase in their personal lives and the CHC team’s support, time,
understanding, fellowship was seen as a very helpful input - a very significant
reaching out!
In more recent years, there have been many NRIs who are returning to the country
with good skills and knowledge and wish to support the process and they too have
been in touch and the supportive process continues.
49. This activity is always high on CHC’s agenda and is also referred to as the ‘coffee
club’ approach in our work, leading to a reputation that CHC is a centre where
you can always find a person interested in your work and interested to learn from
your experiences and at the same time provide professional / technical expertise to
solve the visitors specific problem. This is a sort of information advisory and
vocational counselling service that has been very satisfying but also rather
demanding. While this is a significant contribution, this activity/response also
makes time management more difficult and unexpected number of requests in
chc/msvvord/c:/office/15stone.doc 21
quantity and quality often compromise the system. While recognising the need and
importance of this activity the CHC team needs to find a good balance between
catalyst peer support and focussed definitive commitments.
PARTICIPATORY ETHOS IN MANAGEMENT (tryincj to practise
what we preach)
50. The participatory ethos in CHC’s experimental and Society phase derives
inspiration from a learning experiment of the 1982 Bharat darshan of the co
initiators. It was found that all projects which had participatory, relatively non
hierarchical functioning seemed to have a better morale among the team and was
generally more effective and more sustained in its action responses. The
hypothesis in the CHC experiment was that individuals in teams could not be
expected to build Primary Health Care / Community Health as a democratic
process through interaction with members of the community, if they themselves
did not experience democracy in their team ftinctioining and experience. A
participatory management ethos was thus geared to the development of an
experiential laboratory where new team members understood the challenges and
responsibilities, the approaches and the dilemmas of working with the people.
This factor soon spread beyond the management administrative framework of
CHC and become a touch stone of all our interaction with partners and other
resource groups. So we moved from participating management; to participatory
evalution; to participatory interactive action and policy research. It greatly helped
to get the team to slowly began to consider, partners, team members, other
resource persons, as participants of a joint partnership rather than as beneficiaries
of our specific project initiatives.
51. Participatory evaluations
All the reviews/evaluations, we have done have strong elements of participation.
KSSP (SPT/MK/TN), RTU (SPT/VB/GG), CMAI-CSCD (SPT), ISI (TN), Memisa
Partnership Review (RN/TN), CHAI Study (TN, JJ, TP, XA), DSS (SPT/VB/RKN).
The review or evaluation efforts have attempted to involve all those who
participate in the project being evaluated, plan the process with them and make the
review a learning experience for all concerned.
CHC team members have
therefore, played the role of facilitators of a participatory learning experience
rather than a topdown - outside evaluator.
chc/msword/c:/office/l5stone.doc 22
S. Networking and Solidarity
52. CHC has been an active participant of all the current networks in the country.
These include:
i.
Formal coordinating networks like VHAI, CHAI and CMAI and their
Karnataka based regional networks - VHAK & CHAIKA;
ii. Issue based networks like LSPSS, AIDAN, DAF-K, AIPSN, VANI;
iii. Networks at Asian level like ACHAN;
iv. Thought currents and networks like mfc;
In solidarity, it has supported as many initiatives of all these networks as possible
and has worked closely with many in specific partnerships and in solidarity.
53. From time to time, it has taken up specific leadership roles as well eg..
i.
CHC was the Convenor and publisher of the mfc and mfc bulletin 1984-86;
(RN/TN)
ii. CHC team members have been on the Governing body of DAF-K, VHAK,
INSA; (SPT/VB/TN)
iii. CHC team members have been on VHAI Educational Council; (RN)
iv. Chairperson of Malaria Expert Group of VHAI; (RN)
v. Participated and contributed to report of the Independent Commission on
Health organised by VHAI 1994-96 (CHC was an associate).
54. For a few years, CHC also facilitated a Community Health Network in Bangalore
bringing together all its contacts and resource persons for regular dialogue on
issues related to Community Health. This network then moved from regular
meetings to occasional ones and from general community health issues to specific
ones that could be supported by definitive action initiatives like CHC’s response to
the Latur earthquake, Bangladesh cyclone, Uttarkashi earthquake, all of which
were greatly supponed by the Network. After a few years, the network became an
informal network of associates, forming a multidisciplinary group helping CHC in
its work (the CHC Associates Network).
55. Networks and collectivity building are important needs and CHC’s involvement
has shown that it is possible but not easily sustainable. Cultural factors like
chc/msvvord/c:/office/l5stone.doc 23
dependence, inability to take full responsibility, institutional egos, agenda and
styles of action; and power and prestige issues often prevent networking efforts
from becoming very effective. In absence of true, democratic participation and
ethos, these often lose their focus, their creatively their relevance. However, in
today s climate of alliances - there will continue to be a need for increasing
collective perspective generation and collective action. There is an urgent need for
an alliance in Health which will work together and raise key issues of significance
for the people especially in this growing climate of globalisation, privatization,
inequity and market economic distonions of medicines and health care. CHC will
need to seriously respond to this challenge.
BUILDING COLLECTIVITY INLOCAL/STATE/NATIONAL EFFORTS
IN HEALTH
56. From its very beginning and because of the involvement of some team members
with the mfc network since 1980, and the evolution of the early, VHAI concept of
a community health movement (1975) CHC has all along pushed for this process for this sort of commitment to collective functioning at all levels - local, state and
national level.
From the mfc convenorship; through the Bhopal work, the involvement in the RDP
campaign; and all the way to the recent efforts of building on collective Indian
perspectives on Malaria from the grassroots, CHC has tried to build collectivity.
57. The key collectivity building exercises/initiatives are
*
The Delphi survey was an effort to bring together the predictions of 40 key
health and other professionals in the country;
*
The three meetings of the training network for VHAI, CHAI and CMAI
were for the some purposes;
*
The medical college project started with 4 medical colleges and built up
solidarity and collective interest with 14 institutions by the end of the
process;
*
The Malaria expert group started with 6 expert members in the group but
by the time the report was published there were 44 + reference group
members who had contributed to the report.
*
Finally, the WHO policy process and the 5 city based meetings in New
Delhi, Chennai, Secunderabad, Mumbai and Bangalore - brought together
over 125 health projects and professionals to respond to the document.
chc/msword/c:/office/l5stone, doc 24
However, a sustained collective effort to promote an alliance particularly propeople, pro-empowerment, pro poor, pro ethics, pro-equity, pro
demystification, pro-health issue raising and lobbying are still a distant dream but perhaps a good millenium goal.
U. CHC SOCIETY PHASE II (1993 96) - New directions
58. In the beginning of 1993, RN & TN who had been co-initiators of the Cell,
suggested that from the end of the year, they would like to take a long extended
sabbatical break, to consolidate the perspectives of CHC and also provide space
for alternative leadership and for new directions. From July 1993 till June 1996
this consolidation project was operationalised. Many interesting responses from
the CHC team members and Society members to this ‘opportunity’ lead to a
smooth transition into Phase II of the Society phase:
i.
SPT who had been a part time resource person took over as full time
coordinator and ably handled the leadership challenge;
ii. CMF and VB who had been members of the Society and helped to govern
CHC in Phase I of the Society phase agreed to give time to the centre as
consultants in Planning & Management and Information and Advisory
Service respectively;
iii. Four new young team members were identified and the team was
strengthened at the second level (RKN, AS, VJJ, ARS). Some team
members joined to help the office (JN/AMC).
iv. A major shift in focus was towards grassroots training mentioned in
Section L, Para 34 and described in detail in a complementary report;
The transition into Phase II was important because withdrawal of the full
time co-initiators helped CHC develop new styles of growth and response
without becoming too reliant on specific individuals and resource persons.
v. Some interesting features of this phase was that all CHC contacts
continued to function with CHC and many new contacts developed. CHC
grew in scope and function showing that the links were not personality
centre.
vi. Staff development programmes looked at new dimensions with regular
quality circles and staff transformation workshops including exploration of
spiritual health and the creation of small work groups, etc.,
chc/msword/c:/office/l5stone.doc 25
Many programmes continued and many new directions developed. These have
already been included into “J” to “T”. However, since the number of member level
fulltime resource persons decreased, the overall burden on the new coordinator
was rather excessive further complicated by the intensive travel commitments
necessitated by field level training. After a 3 year period of providing alternate
leadership, SPT decided not to continue and so CHC began the transitional phase
1996-97 prior to the next phase beginning 1998 - under new leadership once again
(this time TN).
V. CHC Consolidation (1994 - 1996)
59. The consolidation phase or extended sabbatical that was operationalised by RN &
TN from January 1994 till December 1995 consisted of many components:
i.
Review and consolidation of CHC perspectives into monographs on
community health and training (a task only partially completed);
ii. Short term formal teaching, and research / evaluation assignments;
iii. TN initiated a Doctoral programme at the Health Policy unit of the London
School;
iv. Extended South-South and South-North dialogue opportunities because of
the northern educational base;
v. Reflections on the future - idea drafts on creative option.
60. The key events/initiatives of this phase were ’.
i.
TN’s initiation of her Doctoral Policy on Public Policy Analysis of TB
Control in India; linked to the Health Policy Unit of the London School of
Hygiene and Tropical Medicine (LSHTM).
ii. RN was linked to Tropical Health Epidemiology Unit of the LSHTM as
an Academic Research visitor facilitating learning session and workshops
on CHC work related themes;
iii. A critical study of World Bank Report - WDR-93 (RN);
iv.
Lecture assignments in Scandinavia - Bergen University (Norway) and
Uppsala University (Sweden) (RN);
v. Editorial Advisory board of AHRTAG newsletter - Health Action (TN);
chc/msword/c:/office/l5stone, doc 26
vi. Three short term review of Indian partnerships for (a) Misereor
Memisa (c) Cebemo & ICCO (RN/TN);
(b)
vii. Review of Malaria Control Programme in India - ODA/Malaria consortium
meetings (RN);
viii.Planning of a short summer course on Health Research in Developing
countries at the invitation of Canadian University consortium for Health
and Development at McGill University (Montreal, Canada) for August,
1995 (RN & TN);
ix. Participation in emerging Health Policy meetings in India, Women Health
(WHO, New Delhi, February 1994), TB Revised Strategy (GOVVHAI),
AIDS Policy (CHAI, Bangalore, June 1994) (all TN);
x. Opportunity to read/review wide diversity of health publication and
interacting with northem/southem community health and public health
colleagues and peers.
The key learning experiences of this phase have been circulated in a separate
document.
W’.
CH^s initiatives in South-North and South-South Dialogue
61. Twice during the 14 years history of CHC, as explained in sections E & V, two
team members of CHC (RN & TN) spend a year linked to LSHTM - London.
Both these years were an opportunity for South-North and South-South dialogue
Lecture Discussions were held in various UK based health training institutions and
NGOs on Community Health in India and related themes.
62. In addition, over the years, TN participated in an evaluation of CBH projects in
Philippines; RN represented VHAI in a 5 country dialogue on Govt.-NGO
collaboration (Indonesia, Philippines, Pakistan, India, Bangladesh) at Yogyakarta;
RN lectured in Canadian Universities (McGill, McMaster and Dalhousie) and
facilitated a workshop on Building Coalitions in Health at the invitation of
Canadian Society of International Health; RN/TN lectured at Coady Institute,
Antigonish; RN at Bergen University (Norway) & Uppsala University, (Sweden);
TN attended the conference of the Network of Community Oriented Health
Science Institute at Sherbrooke (Canada); SPT led teams to Bangladesh for4
cyclone relief; and Sri Lanka to help in the Tamil Refugee camps; RN also
facilitated a workshop on State of India’s Health at Aachen, Germany, at Misereor
Head Office; and both RN & TN have provided policy reflection at Cebemo,
Memisa, Misereor headquarters in Europe.
ch c/msyvord/c:/office/l 5stone, doc 27
63. More recently the WHO Policy process document - Renewing Health for All had
active CHC participation in many preparatory meetings. At Geneva, WHO-NGO
dialogue (April 1997) (RN); at WHO Assembly - International NGO forum
meeting (May 1997) (RN); at Geneva, meeting on Equity (September 1997) (RN
& TN); at Helsinki, meeting on Sustainability (November 1997) (RN & TN); at
London meeting on Poverty and Health (December 1997) (RN & TN) and on
Business & Health (December 1997) (RN).
X. The Challenge of Mainstreaming
64. In the last two years, particulars CHC has begun to get invitation from
Government to participate in policy reflection, evaluation and training strategies in
Health. This new development in very significant because CHC is now getting
opportunities to impact on mainstream health care providers, action initiatives and
developing policy.
Some significant recent examples are:
*
Training of all medical officers of IPP-VIII MCH Centres in Bangalore in
Management issues;
*
Review of Jana Swasthya Rakshak Scheme in Madhya Pradesh and
organisation of a Peer group review' of the Diarrhoea Control Mission in
Madhya Pradesh;
*
Participation in the development of an IGNOU linked CME course for
ANMs in the country;
*
Reflections on a Population Policy for Karnataka organised by ISEC and
other institutions;
*
Involvement in restructuring of the MBBS course with Rajiv Gandhi
University of Health Sciences in Bangalore, Karnataka;
Apart from being an opportunity to promote a paradigm shift in mainstream
thinking, the opportunities also a challenge to CHC team to begin to make an
impact on the system by small incremental changes from within. We need to be
realistic in our expectations but even small percentage changes in attitudes, skills, >
knowledge or perspectives can have major effects/impacts on the system.
ch c/msword/c:/office/l Sston e.doc 28
Y. CHC Communications / publications
65. The CHC publication list, one of the outcome of the consolidation project shows
that communicating ideas and perspectives has been a major contribution of CHC
during the entire phase.
The topics covered have been Community Health, Health Policy, Health Human
Power training including Medical Education, Rational Drug Policy and Rational
Therapeutics, Alternative Systems of Medicine, Bhopal Disaster, Environment
Health including Agriculture & Health, Child Health, Womens Health, Family
Health, Disaster relief and response. Medical Ethics, CBR and more recently
Malaria & TB among the communicable diseases.
The medium was primarily existing bulletins, magazines and journals which
included EPW, Health Action, HFM, CMJI, Link (newsletter of ACHAN), mfc
bulletin, Madhyam Journal, Annals of Community Oriented Education, Trends in
Medical Education, Medical Ethics, bulletin, and so on.
66. As publication of CHC - there have been seven newsletter over the years but these
have been mostly information on our work and some perspectives from the
initiatives, circulated mostly to all our friends, associates, contacts and visitors to
CHC.
The Medical Education Project resulted in three published reports and 2
photocopied reports and the CHAI study resulted in the Document entitled
“Seeking the Signs of the Times”.
More recently CHC has been having good interaction with medical persons and
journalists and CHCs perspectives and concerns are being written about in Deccan
Herald, Times of India, etc.
CHC team members have just begin to use AIR and Doordarshan opportunities to
promote Rational Drug Use through DAF-K initiative.
Perhaps, lobbying through the media must be explored further in the years ahead.
67. CHC’s collections of posters are used by NGOs for training, exhibitions, camps
and jathas. These include our own informal productions and also collections from
VHAI, CHETNA and other health education material producing organisations.
The only slide cassette set (now available as video) which CHC has produced in its
14 year history - is the popular Ramakka’s Story - which has been used extensively
in training programmes as a starting point to a discussion on Rational Drug Policy
issues or Community Health issues.
ch c/msyvord/c:/office/l Sston e.doc 29
Z. WHAT NEXT - on the edge of a Medtamorphosis
68. CHC’s 14 year history and process has seen many challenging opportunities and
interesting initiatives.
*
From a small team of 4 it has gradually become the Centre of a large
network of Society members; CHC team members; CHC associates; CHC
friends and CHC contacts.
*
It has a wide matrix of linkages and is involved with all the key health
related networks or associations in the country.
*
It has promoted the concept of a paradigm shift in health action and has
promoted collectivity in Indian experimentation and initiatives in Health.
*
It has explored Community Health and many of its dimensions through
collective reflection, informal panicipatory training, interactive research
and has tried to enhance the enabling empowerment dimension in action.
*
It has done all this through a small intensely involved catalyst team keeping
a participatory management and a low cost, simple ethos and an open
ended catalyst approach to requests and has been responsive to emerging
needs.
*
All along it has tried to build up an increasing solidarity of collective
action; an increasing commitment to developing counter expertise which is
pro-people and rooted in Indian experimentation and perspective that has
links with grassroots action.
69. Second line leadership crisis
CHC has reached the 15th milestone facing many challenges and responding to a
wide range of opportunity. The continued involvement of the core leadership (RN,
SPT, TN and earlier KG & MK) have made these 15 years sustainable even though
there have been changes from time to time in the level of linkage by them, due to
short-term bum out and or phases of further study. The support of the Society
members especially ‘the three wise men’ of the experimental phase and all the
others who are presently members of the Society, and the rich diversity of the
multidisciplinary professional CHC associates network has been significant and the
core leadership have been constantly supported, encouraged and stimulated by it.
Over the years (see Appendix) many other team members have joined for short
term or longer term linkages, and time and effort have been spent to provide
ch c/msword/c:/office/l 5stone, doc 3 0
support and encouragement for some to seize the opportunity to become the core
of the second line leadership.
However, a wide range of factors have contributed to this process not being
sustained and all potential second line leadership have moved on to other options
either due to career advancement plans, matrimony, or unable to manage the
demands and challenges of CHC type work, which apart from its interesting
opportunities also has its own insecurities and pressures.
More recently, in the last few years, with the development of the concept of
Training/Research Associateships / and Assistantships, many young professionals
and potential team members have operationalised short term linkages to find time
and space to consider areas of common interest with CHC, and also to get to
understand CHC’s framework and structure.
We believe that we may just be on the threshold of the discovery of a new second
line - that could gradually take over from the core first line, over the next phase.
CHC has tried to address the ‘insecurities’ and related issues through new policies
and new forms of linkages may be on the anvil.
However - the second line leadership issue remains a major concern of CHC,
inspite of all our efforts. The challenge is to find a small group that is able to
recognise the phenomenal potential and opportunity that the core team has
experienced through the development of this interactive/responsive Community
Health Oriented Cell and facilities over 4 phases and be willing to take it over and
respond to the emerging challenges of the next millennium.
70. CHC has now reached an important ‘milestone’ - which is why the review has been
initiated.
There are many options before it as it reaches towards the end of the millenum:
1. Continue the catalyst ethos and explore new ideas, initiatives, responses;
2. Metamorphose into a Centre for Community Health which builds on its 14
year experience and large and creative matrix of linkages and undertake
more proactive training and policy research projects to impact on the
mainstream system;
3. Facilitate the evolution of an Alliance of Health - which is pro people, pro
poor, pro equity, pro ethics, and which helps to harness evolving
community health action into a peoples movement;
ch c/msword/c:/office/l 5ston e.doc 31
4. Do 1, 2 and 3 or combinations of them?
5. Do something else which is urgently required and very specific perhaps and
which best draws upon its unusually responsive, interactive, collective
experience?
AS WE MOVE TOWARDS 2000 AD AND HFA IS A DISTANT
GOAL WHAT SHOULD BE CHC’S ROLE?
ch c/msy\>ord/c:/office/l5stone, doc 32
CHC Team : Past - present - Future (in order of joiniTiq)
1. Ravi Narayan * (RN)
2. Thelma Narayan * (TN)
3. K. Gopinath (KG)
4. Krishna Chakravarthy (KC)
5. S. John (SJ)
6. Shyam Sunder (SS)
7. Shirdi Prasad Tekur * (SPT)
8. Mani Kalliath (MK)
9. M.S. Nagarajan (MSN)
10. V.N. Nagaraja Rao * (VNNR)
11. Raphael Udayakumar (RU)
12. M. Kumar * (MK)
13. S.J. Chander (SJC)
14. Xavier Anthony (XA)
15. C.M. Francis (Consultant) * (CMF)
16. V. Benjamin (Consultant) * (VB)
17. C. James * (CJ)
18. Nalini Gururaj (NG)
19. H.N. Vishwanath (HNV)
20. R. Murali (RM)
21. Reena K. Nair (RKN)
22. Anjana Srinivas (AS)
23. J.V. Jaimon (JVJ)
24. A.R. Sreedhara * (ARS)
25. Jayachitra Narayan (JN)
26. Apama Chintamani* (AC)
27. H. R. Mahadeva Swamy * (MS)
28. Joseph Anthoniappa * (JA)
29. Rajan R. Patil * (RRP)
Research/Trainin^ Associates/
Assistants
1. Magimai Pragasam (MP)
2. Johny Jacob (JJ)
3. Tomy Philip (TP)
4. Arvind Kasturi (AK)
5. Madhav Ram (NIR)
6. Soumya Kumar (SK)
7. C. Mallu (CM)
8. Madhukar Pai (MP)
9. Rakhal Gaitonde (RG)
10. N. Devadasan* (ND)
11. Denis Xavier* (DX)
12. B. Murali (BM)
Volunteers
1. Sumangala Pai
2. AnupamaM.C.
*
in team currently
( ) Abbreviation used in report
chc/msyvord/c:/office/l5stone.doc 33
CHC Associates
1. Fr. Claude D’Souza * (CMF)
2. Dr. George Joseph * (GJ)
3. Valli Seshan * (VS)
4. Mohan Isaac* (MI)
5. M.J. Thomas* (MJ)
6. A. Arumugham *
7. H. Sudarshan* (HS)
8. Paresh Kumar* (PK)
9. Prof. S.V. Rama Rao* (SVR)
10. Dr. M.K. Vasundhara *
1 l.Dr. D.K. Srinivasa*
12. Ms. Vatsala Nagarajan*
13. Ms. Padmasini Asuri*
M.K. Gopinath* (KG)
15. Mani Kalliath* (MK)
16. Gopal Dabade
17. Prakash Rao
IS.Vanaja Ramprasad
19. Uma
20. K.V. Sridharan
*
21 .Saraswathi Ganapathy
22. Veda Zachariah
23. Pankaj Mehta
24. As Mohammed
25. Wg. Cdr. S.K. Krishnan
26. G. Gururaj (GG)
27. T.N. Manjunath
28.S.B. Pruthvish
29. Arvind Kasturi
30. Girish
31 .Muralidharan
32.Kishore Murthy
33.Satish Rao
34.G.D. Ravindran
35.Sanjeev Lewin
36.Sukhant Singh (SS)
37. Dhruv Mankad
38. Madhukar Pai
39. Ravi D’Souza
Members of SOCHARA
chc/msyvord/c:/office715stone, doc 34
CHC Associates
1. Fr. Claude D’Souza * (CMF)
2. Dr. George Joseph * (GJ)
‘^3. Valli Seshan * (VS)
4. Mohan Isaac* (MI)
5. M.J. Thomas* (MJ)
6. A Arumugham *
7. H. Sudarshan* (HS)
8. Paresh Kumar* (PK)
9. Prof. S.V. Rama Rao* (SVR)
TO.Dr. M.K. Vasundhara *
1 l.Dr. D.K. Srinivasa*
(12.Ms. Vatsala Nagarajan*
<13.Ms. Padmasini Asuri*
14. K. Gopinath* (KG)
15. Mani Kalliath* (MK)
16. Gopal Dabade
17. Prakash Rao
LlS.Vanaja Ramprasad
(19.Uma
20.K.V. Sridharan
(^H.Saraswathi Ganapathy
<22. Veda Zachariah
23. Pankaj Mehta
24. As Mohammed
25. Wg. Cdr. S.K. Krishnan
26. G. Gururaj (GG)
27. T.N. Manjunath
28.S.B. Pruthvish
29.Arvind Kasturi
SO.Girish
31 .Muralidharan
32.Kishore Murthy
33.Satish Rao
34.G.D. Ravindran
35.Sanjeev Lewin
36.Sukhant Singh (SS)
37. Dhruv Mankad
38. Madhukar Pai
39. Ravi D’Souza
* Members of SOCHARA
chc/msword/c:/office/l5stone.doc 34
THE CHC REVIEW (19&4-97)
(A celebration and group reflection at the 15th milestone)
Date
: 3rd and 4th April, 1998
Venue
: The Brothers of Holy Cross, 47, St. Mark’s Road, Bangalore - 560 001.
Time
: 9.30 a.m. to 5.00 p.m. (both days)
Participants
1. All members of the Society for Community Health Awareness,
Research and Action
2. Invited team of Reviewers
3. Some CHC Associates
4. CHC team - Past and Present
DAY ONE
3rd April
(Friday)
THEME : Learning from the Past and Present
SESSION I - Introductory session
ChairPerson : Fr. Claude D’Souza
9.30 a.m.
Invocation
Welcome and background to Exercise
Self introduction by Participants
VB
10.00 a.m.
The CHC at the 15th Milestone
(An overview of 1984-97)
RN
10.30 a.m.
Clarifications
10.45 a.m.
Tea
SESSION II - CHC : Some Vignettes
Chair Person : Dr. D.K. Srinivasa
11.00 a.m.
Overview of interactive Research
- issues and challenges
11.30 a.m.
Comments and clarifications
11.45 a.m.
Urban Health Initiatives
SJC
12.00 a.m.
Rational Drug Campaign
DX
12.15 p.m.
Integration of Medical Systems
RRP
12.30 p.m.
Comments and clarifications
1.00 p.m.
Lunch
TN
SESSION II (Contd.)
Chair Person : Dr. V. Benjamin
1.45 p.m.
1. Training - middle level and field level
2. Participatory Evaluation
2.15 p.m.
Comments / clarifications
SPT
SPT
2.30 p.m.
Building the alternative paradigm collectively
3.00 p.m.
Comments and clarifications
3.15 p.m.
Tea
RN
SESSION III : CHC Management: An overview
Chair Person : Ms. Vatsala Nagarajan
3.30 p.m.
Organisation for Catalysis
CMF
4.00 p.m.
Financial Management
MK/KG
4.15 p.m.
Staff Development
AMC
4.25 p.m.
Library & Documentation Unit
SJ
4.35 p.m.
Comments and clarifications
(End of Session - 5.00 p.m.)
DAY TWO
4th April
(Saturday)
THEME : Reflections, Critiques and Directions for the Future
SESSION IV The CHC Experiment: Reflections, Critiques
Chair Person . Dr. C.M. Francis
9.30 a.m. 10.45 a.m.
All Reviewers / Participants
10.45 a.m.
Tea
11.00 a.m. 12.30 p.m.
All Reviewers / Participants
12.30 p.m.
SWOT ^Analysis by CHC team
1.00 p.m.
LUNCH
OX
SESSION V : Scenario Building Together
Chair Person : Dr. H Sudarshan
1.45 p.m. to
2.15 p.m.
Scenarios from various initiatives of CHC
RN/TN/SPT
2.15 p.m. to
3.00 p.m.
Comments and suggestions
All
participants
3.00 p.m. to
3.30 p.m.
Tea
3.30 p.m. to
5.00 p.m.
SESSION VI : Concluding Session
Chair Person : Dr. Mohan Isaac
Priorities and Directions for the future
All
participants
and CHC
team
f
COMMUNITY HEALTH CELL
BANGALORE
REVIEW
DRAFT FOR DISCUSSION
Amar Jesani
Mumbai
September 18, 2004
f
The report is divided into the following sections:
•
•
•
•
•
Terms of Reference
Methodology
Findings pertaining to Terms of Reference and any other relevant observations
Discussion on some crucial issues in the priority concerns of the organisations
Suggestions for the way forward
Acknowledgement: My sincere thanks to all who cheerfully spared time to share with
me their experiences with and the views on the CHC, at my convenience. My thanks also
to the staff of the CHC who made my stay and travel in Bangalore comfortable.
2
f
TERMS OF REFERENCE
A team of two external persons were supposed to undertake this review, but one of them
team’ ThuS’ With the cooPeration ofthe team members drawn from the
oOCliARA, this review was completed.
The Terms of Reference for the review very broad and all encompassing. Although they
provded free hand to reviewer, all issues in the terms of reference could not be
adequately dealt with in the review process. The Terms of Reference were as follows:
1. The philosophy in founding the Community Health Cell. The objectives at that time
Modifications of the objectives - what, why, when? The present objectives. To what
extent have these objectives been achieved?
2^ The organizatmnal structure of the Society (CHC). Is this optimal to achieve the
0/ieCt'7£? .^Qdifications, if any, needed to achieve the objectives better. Recruitment
of Staff, training and re-training. Staff development programmes and their usefulness
js Jhe
Ji; n de!B0Cl..nic ,
: in
r<1 o :
. ...... t
Ox the Society and taking action on the findings?
~ • —— Lioii ui iitc iuiicLiJilin2
3. Strengths, weaknesses, constraints and opportunities. Have the strengths and
opportunities been utilised to achieve the objectives? How have the constraints and
weaknesses been reduced / overcome?
t \alueS
llfe styles °.f the Socicty members and team. Did they have any impact on
the functioning of the Society and on other organizations / people? If yes, how?
5. Important programmes of the Society (CHC) and their impact - local, state, national
international. Involvement of the Society in advocacy and networking with other
organizations - governmental and non-governmental; experiences and learnings from
them.
6
6. Quality assurance in the activities of the society. What are the procedures in place to
assure quality? What steps are needed to assure better quality?
7. Society (CHC) as a Ilearning organization. How has the Society (CHC)' utilised its
programmes for learning by the members / staff and iin creating awareness leading to
action among the people on the health related problems?
8. Contributions of the Society (CHC) to equity, social justice, environmental and gender
issues, intersectoral action, community organization, mobilization and participation and
empowering the people, especially the disadvantaged.
v
9. Contributions of the Society (CHC) towards health planning and policy formulation of
the state / country. Involvement with the Panchayati Raj institutions at the district Taluk
and village levels.
10. Have there been innovative, creative contributions made by the Society (CHC)? If
yes, what is their impact?
1 L Education/trainmg: what has been the involvement of the Society (CHC) in training
and education in Community Health? Public Health? Is there a need for greater
involvement? If yes, how should this be done?
12. Management of finances of the Society (CHC).
sustainability in the long run?
How can we ensure financial
13. Factors, which facilitated the Society (CHC) to work as a team.
enhance teamwork.
dh-e^ons11'11611'13110115
Suggestions to
improVed functioning of the society and suggestions for new
4
METHODOLOGY:
1. The SOCHARA made available the documentation of last 20 years, starting from it
inception 1984. The documentation included reports and publications of the CHC, from
1991 onwards the minutes of the meetings of the SOCHARA and the executive
committee minutes, the financial information of last five years, the documents pertaining
to work plans, the previous review of 1990 and 1998, various writings related to the CHC
and its work, the newsletters of the CHC, rules and regulations of the society and so on.
All of them together run into over 1000 pages of documentation. The reviewer spent lots
of time going through the documents, though selectively, in order to get a fair idea of the
mission and history of the organisation.
2. An internal review of the CHC by the staff was iundertaken
’
between April and
November 2003 in five meetings. A draft of the internal
---- 1 review report was made
available.
3. A mailed survey of opinion of members of the SOCHARA and associates; was
undertaken by Dr. Mohan Issac, president of the SOCHARA. 27 individuals responded to
this questionnaire. A summary of their responses was made available to the reviewer.
4. Starting from January 2004 at the World Social Forum, the reviewer conducted a series
of interviews with the individuals presently working at the CHC, those who have left the
organisation, those who associated with their work in some capacity, some of the
members of the SOCHARA, some individuals and organisations who have associated
with the CHC/SOCHARA from time to time in collaborative work and one meeting with
the Bangalore based field workers involved in field based project of the CHC. Two
individuals were interviewed using email and telephone.
The following individuals were personally or on email/telephone interviewed in this
process:
Those presently working with or associated with CHC:
Dr. CM Francis,
Dr. Thelma Narayan,
Dr. Ravi Narayan,
Dr. Paresh Kumar,
Ms. Sylvia,
Mr. Prasanna,
Mr. Krishna Chakravarthy,
Dr. Mohan Isaac,
The CHC administrative staff in groups - Ms. Noreen, Ms. Deepu Shailaja, Mr. DG
Srinidhi, Mr. James; Dr. Rajendran
5
Those who have worked in fthe past (full-time, part-time or associated in some capacity).
collaborated in some work , are presently collaborating, members/associa^es of
SOCHARA, etc:
Dr. Anant Bhan,
Dr. Sabu George,
Dr. Rakhal,
Dr. Naveen,
Dr. Abraham Thomas,
Dr. AR Shreedhara,
Fr. John Vattamattom,
Fr. Tom (CHAI)
Dr. Mani Kaliath,
Dr. Nirajakshi (Karnataka VHA),
Dr. Shekha Sheshadri,
Dr. Girish Rao,
Dr. LC Jain,
Dr. Rajagopal (NIAS),
Dr. DK Srinivasa,
Dr. Unnikrishanan,
Dr. H. Sudarshan,
Dr. As Mohammed,
Dr. Danis Xaviers,
Dr. Sanjiv Lewin,
Dr. Shirdi Prasad Tekur,
Ms. Valli Seshan,
Dr. N. Devadasan,
Dr. Rajan Patil,
Dr. Sampath Krishnan,
Mr. Anant Padmanabhan (GreenPeace, India)
Totally over 40 persons were interviewed, some of them iin more than one sitting while
some were interviewed for only few minutes.
A brief note on my experience in the review process: A few important issues must be
put on record so that the findings and the over all report of the review is better
appreciated:
(a) 1 know CHC for last more than 20 years now. I have been its admirer and at the same
time, as it is my researcher’s temperament, its critic. One’s respect, personal friendship
with the leading group of the individuals, etc could become some handicap in objective
assessment of the task at hand. I did feel some conflict of interests or to put it better,
some amount of confusion and tension, and emotional turmoil while doing this work. It
6
often slowed me down, and at least once made me to question myself the wisdom of
accepting this work.
(b) My work was made bit more difficult by the fact that many of the informants or
respondents whom I interviewed were also known well to me, though not as well as Ravi
and Thelma are. They trusted me and tolerated my way of interviewing. I often became
very provocative, taking position of devil’s advocate in order to make the informant give
the best response on the topic. They mostly tolerated this, and gave me as frank
information as possible. More than once I was told that they were giving some sensitixe
information or view simply because they trusted me, or thought that at least I would bring
i make note of it in my report. I do not know how far I have succeeded in giving
representation to such points, but surely such information made me to work and think
overtime to judge about how to assess and interpret such information.
(c) Lastly, I noticed discrepancy in the responses given by individuals to me and in their
opinion given in writing to the organisation. This was partly due to the fact that in
personal discussion one tends to elaborate and explain better than in writing brief
responses to questions. But in four cases there was major variation in the content making
me uneasy about what to use as authentic. Ultimately I decided to use the information
piovided to me in interview or on email as authentic position of the individuals and I
nave used the same in the report.
7
FINDINGS IN RELATION TO TERMS OF REFERENCE
(A) PHILOSOPHY AND VALUE SYSTEM OF THE ORGANISATION, VALUE
AND LIFE STYLE OF MEMBERS:
hese aspects of the CHC/SOCHARA are considered to be its greatest strength. On
scanning through the documents from the very inception of the organisation, there is
constant explicit commitment to certain type of the organisational philosophy and the
value system. Under the rubric of philosophy and value system one finds several things
mentioned. The philosophical understanding of voluntarism and its necessity, the way
one looks at the health issues - the social paradigm of health, the appreciation and faith in
collective community actions, participatory way of functioning, non-hierarchical
relations hip, commitment to equity and empowerment, and so on. My first discover.'
w ule interacting with many individuals during the review was that these terms were used
by most of them, but their meaning was understood differently or not understood at all. A
part of the problem is that these terms are very general, with omnibus meanings.
Voluntarism, participation, non-hierarchical relationships etc. need rigorous discussion
and consensus development on how they are operationalised in the CHC's international
functioning, work and in its relationship with other organisation. Keeping this in mind I
probed only few elements of philosophy as they were viewed as well as perception of
their actual operation at the organisational level.
Voluntarism:
I got different meaning of voluntarism from the SOCHARA members who are not
'y°Ip12.?.in the CHC than those individuals who work or worked in the past as full time
staff. I bis was m a way natural and found so in many NGOs. The SOCHARA members
®ltaer professionals involved in their own work or come from more institutionalised
NGO background or are retired from some such work. On the other hand are those staff
members of the CHC, who are not or were never a part of the SOCHARA. With a few
rom each category I had some discussion on this aspect, with the rest such issues came
up by chance or I was enlightened indirectly.
I could discern three levels of understanding of the voluntarism. The first level was more
at the individual level, wherein I was told why it was necessary to get involved in some
voluntary activity while being engaged in one’s own mainstream work. The justification
tor that ranged from religious to simple need to derive satisfaction and give back
something extra to the society. At this level, there was deeper commitment to the
individual morality. The second level was more political, and associated it with the need
tor social change. The voluntarism was to undertake activities, both professional and
l?°'tlC|a ’that could lead t0 some impact on changing, for better, the lives of the deprived
And third level was more pragmatic, and looked at the voluntarism as a part of more
satisfying career choice. At this level the responses ranged from the idea of assisting
8
those who were doing good work, to attraction for involving in organisation that was not
bureaucratic, allowing some initiative and experimentation of new ideas. No individual
responded only at one level, all of them used points that partially overlapped at least with
'n°rC e\eL Interestmgly, one relatively new staff member felt very sad that in the
NGO sector the staff were becoming more of full time functionaries and losing their spirit
o voluntarism. The voluntarism as non-remunerative, altruistic and purposive action
came more from those who did not depend upon the CHC for their basic survival or who
had other sources of income.
At another level, there appeared to be some amount of conflict between the work as
professional commitment and voluntary activism. The professional staff, most of them
interviewed not presently working with the CHC, expressed more dissatisfaction to
voluntarism that misguidedly reduced the professional commitment to work and
ideological orientation that prevented balanced appreciation of evidence. On the other
and, one former professional staff and one present staff lamented about increasing
orientation of the CHC to research, projects and professionals at the detriment of
voluntarism and activism. These two diametrically different perceptions flow from the
dilemma of transiting the CHC to be an institution in last five years.
The voluntarism in terms of organisational activities is evidently very high This is
because of its foundational principle of being catalyst. As a consequence, last two
decades of the organisational work show tremendous awareness of responding to
disasters - both natural and social, responding to smaller and rural organisations whether working as organised groups or as informal voluntary group on wide variety of
issues - health as well as non-health, professional support to various social groups and
movements, participation in democratic rights and human rights movements and groups
etc. etc. Such activities were evidently taken up irrespective of having specific projects
on such subjects and at the risk of over-burdening the staff with multiple activities. Thus,
irrespective of how individual members of the organisation perceive voluntarism, one
gets strong impression that organisation as such is not driven only the funded projects but
by certain commitment to voluntarism.
Participatory:
imilarly the appreciation of the term participation was different among the SOCHARA
members from the staff, and within staff there were perceptible difference between the
administrative and non-admmistrative staff. Before I go into details of responses, it must
be said again that discovery of differences is not new; it has been there in most NGOs.
icre is bound to be variation in the understanding of the initiators of the NGOs and
those who join later on, the variation is also related to one’s ideology, with the position
one has in the organisation and the aspiration. What is important is the consciousness that
such participatory method is considered good and desirable, and such consciousness was
very strong among all interviewed.
9
1 he members of the SOCHARA either looked at the participatory functioning as the most
suitable way or they assumed that that is how, broadly, the CHC is functioning. Within
the CHC, the participation is looked at as ethos and process; and not as systematic
component of organisational structure. At the heart of participatory processes and
structures is the willingness to promote participation, so in a way it is difficult to judge
whether one should rely more on processes or structures. However, a combination of the
two is an ideal situation but difficult to sustain.
In the CHC I discovered that all people I met testified to the participatory functioning of
the organisation. The responses ranged from defining participation as consultation by the
seniors with juniors to participation in decision-making. The former was stated by all
while the latter was mentioned by only a few persons. The critical elements in my
discussion with the staff on issue of participatory functioning were high level of
appreciation for discussing issues with as broad a layer of individuals as possible, so
much so that there were criticism of being too consultative and thus wasting time in
meetings on one hand, and on the other hand some disquiet on the way decisions were
made, the criteria used for decisions taken, opinion of the person not finding echo in the
decisions, etc. However, there was general appreciation of the fact that some space exists
in the organisation to question decisions or have a discussion on the subject. Some
individuals in discussion mentioned their unhappiness about certain decisions but at the
same time were very clear in their appreciation of openness and humility that exists in the
decision- making bodies.
Some disturbing comments were also received. A non-staff member who, while
appreciating greatly the commitment to participatory way of functioning, informed that
he had heard from others as well as from some junior and senior staff members that
decision-making in the CHC was too centralised in the hands of one or two persons and
that there was one individual pulling strings from behind those two decision-makers.
However, he refused to give his source, and since no staff member mentioned it to me
despite my probing, I was not able to validate this information.
A former senior staff member felt that organisational environment was not conducive to
the articulation of problems of the staff as it was looked down upon as trade union
activity, and as a consequence, some of the staff members could never make their
grievances or views heard. He also felt that there was not much encouragement to bring
together staff on non-work basis - like picnic, cultural events. At least two other persons
— one former staff member and one who spent few months there getting initiated to
community health made critical remarks of the issue of participation. One of them called
the environment paternalistic, and thought that it was useful to begin with but as one
grew on the job, it started stifling. Another called it paternalistic and condescending, and
thus, participation was at the mercy of the need of the top leadership rather than as a need
of the staff. These three and two others who had worked with the CHC (as staff or as
trainee), and one senior staff member commented about the lack of autonomy in work,
and that being justified as the need for participatory functioning.
10
Political philosophy:
There two essential elements among others that characterise SOCHARA/CHC’s political
philosophy, viz. community orientation and social paradigm of health. Both these
e ements are very broad, their meaning need to be upgraded based on the accumulation of
empirical data and their practical application tested in specific contexts. Going through
nhtHJ^°rki10f T tW° decades’ 1 8et an impression that the CHC has operationalised its
philosophy in three major ways:
ro e, networking, grassroots (community-based NGOs and others) training etc, fall in this
category. However, it must be noted that the CHC has not opted for its oxm long-term
area specific community work.
6
b. The social aspects of illnesses, social-economic conditions affectins health and
illnesses promotmn of healthy practices, etc. have been taken up both for research as
well as educational campaigns and training.
c. While general critique of the health service system and commitment to primary health
care were integrated in the social paradigm from the beginning, their expressions were
trans f
f
healtH
SyStem’ In laSt few yearS’ the CHC has made
transition from generahty of critiquing health system to touching basic contours of the
system and design its research and advocacy plans around them.
Generally there seems to be a dynamic development of political philosophy - from a
voluntarist critique and civil society efforts to training and consciousness-raising to a
more system research and change approach. If one takes this dynamism as a break from
he pas than one is likely to conclude that CHC has radically changed its philosophy, but
it one looks at it in a more integrative manner than it can also be said that the CHC is
making efforts to strike balance between the three. It is not possible to pass definite
wS T i 'T1101} “ °f n°W’thC dynamic of further development in coming time
would make clear the real trajectory.
S
^e'mn ?Tin8
S°me 35 r3diCal Change *n pri°rity’ 1 believe that evolve
cannot be
r r "n
he31th
health SCrvice SyStem is more comPlex and
cannot be simphstically explained. The terms such as de-professionalisation needs to be
oZJdm°ref C10Sely and Yeighed against the strategy of regulated and ethically
ommitted profession. Similarly, demystification needs to be related to people’s and
patients right to information and patients rights within the health system. Thus, while the
basic political philosophy of the SOCHARA/CHC is not outdated, the need for its
11
shouidhe1!116?’^131'011 3nd application in changing situations must be appreciated and
should be looked at as a positive part of the CHC.
PP^eiaiea ana
1-
against this interpretation of mine, there are few strong critical remarks on the
caXies0tfc,'8 7"'“" ’"<l i.iSC“SSi°n- TheSe remarks c“ be Wd in
,. &
'
lrst category remarks show extreme alarm on the CHC fast
3XTthX‘,ir“?i,y, “c",a,i<’"”
extreme show H
r Pr y OnentatlOn- The second “tegory of remarks are from other
‘Wd
Sb°w dlssati,sfactlon over the CHC’s refusal to shed its “ideology” in favour of
criticise
CHC Cfoealthh’’’ refUSh1 m^3"86
'angUage 3nd pnOr'ty °f work’ and
criticise the CHC for having half-baked, hesitant (vacillating) approach to
Le^-Tfew118 'c W°rk' In;ereStin8ly’ the SOCHARA members am divided on this
professional^
? r
S
CategOry’ but the former staff menibers from
second cateX '
311
bel°nging t0 the
7'" ’'t”"' Un<ier scru,iny in “mi"S
" before
needs to be d Jf
h integrative character of development emphasised. More work
be done to ensure that wrong perceptions do not generate destructive debates.
Others issues related to value system:
Talking to some of the senior members of the SOCHARA I was deeply impressed bv
their concerns such as commitment to such mundane things as simplicity and cleanliness
s Zd° s.™/
,hfe
‘ of "™8
£
cot
r a ua1/unskXd w u
n n
UCIIlg gUlf betWeen the intellectual/spec.alised and
hiahX7 t k d r
allowing the ratio of remuneration to the lowest and the
them I amtold7 a°r
r° JTr 4’ n°n-hierarchical relationship and functioning. All of
been made to operationalised'^themXXheleyX?effOrtS haVe
Evidently, operationalisation of such values was not found to be so easy In last 20 vears
au bT6 eXpe™lentec[’ discarded or modified. For instance, the idea of reducing the
L atlXTreate condT
iS
attamab'e in a"y organisation unless we
and very hi Jh st h
7
C m’nimUm eduCation and ski11 of a" staff is same
labour in S’ t SI
°n may pr°Vide and obJective basis por not having division of
througl^voluntarisiStn
h13™3'
intelleCtUal)' Oncoming such division of labour
or °nft
n
organisation is not only unsustainable, it could also make
o gamsation au hontarmn by forcing those who are not convinced about i Thus certain
ethTa1 code Tthe""6
°f
mOrality’ b is difHcuh to ZkeXm
a d sus a n b
C ^H’5311011 W,th°Ut
^-condition for making them practical
12
While I think that value such as promoting equity by ensuring appropriate ratio of basic
pay between the lowest and the highest salary is both appropriate and to certain extent
sustainable, we need to review it regularly to ensure that organisation does not lose^good
professional due to that policy. The staff and ex-staff members of the CHC are divided on
this issue. The professional staff is critical of this policy as they find that it is a hindrance
to paying higher salary to them, the staff at the lower level find it a good policy as they
get salary at the level higher than available elsewhere. This criticism of the
operationalisation of value CHC considers important is going to only increase.
The sustainability of this value is directly proportionate to three critical factors: (a)
Having senior professional staff with commitment to working at low salary or they have
other family sources not requiring good salary, (b) The CHC is looked at and used only
as the administrative support base of for the otherwise full-time employed professionals
in the SOCHARA and thus the CHC not having any paid full-time professional staff, (c)
By technologically upgrading the work system so that the low paid non-professional staff
is not required.
All three options are difficult ones. In the (a), almost all NGOs have found difficult to get
professionals not needing “decent” salary. Adhering to this factor has either made the
founders as the only professionals in the organisation or they have attracted only the
spouse of well-paid professionals or businessman looking out for semi-voluntary
employment or they have attracted retired professionals. This inevitably pushes out the
professionals hailing from lower strata. Such individuals would be there to use the
organisation as stepping stone for higher jobs. The strategy (b) would change the CHC
from functional centre of the SOCHARA to its administrative centre. And (c) would
make the CHC without peons/office assistants and secretaries, thus demanding
technological up-gradation - a debatable value in itself in the SOCHARA.
I found the issue of technology, location and space as value related considerations as part
of value debate in the SOCHARA/CHC as somewhat misplaced and extreme. I believe
that practical considerations rather than moral should be applied on these issues. The
politics of technology or ideological underpinnings of technology and technological
change should be separated from the appropriate practical use of technologies and space.
Lastly, the issue of life style of individual members is problematic. There are over 30
members of SOCHARA, and then we have staff members of the CHC. There is no way to
find a uniform consideration in the way each member lives his or her life. There are also
variations in the extent of social and family support each one enjoys, as that could be
important consideration for taking risk in life. And at another level, it is difficult to
determine the appropriate standard or level of life style that could be adequate for the
value system of the organisation or for the simple middle class living in present-day
urban jungle of India.
13
Summing up:
Issues related to philosophy are not easy to resolve. More so if the philosophical
considerations and values; are eclectically put together. Somehow I kept getting a feeling
that the list of values to be followed is too long, too eclectic, not ha\ ing a coherent
structure or being part of one theoretical position. This was less problematic when the
organisation was small, was trying not to be become an institution, did not require more
professional staff for undertaking projects, etc. For at the time, the value system was
judged more in terms of its founder’s or Ravi/Thelma’s value system rather than value
system of all members and staff. With the SOCHARA growing into big organisation
(over 30 members) and expansion of staff and work of CHC, the longer list of values and
philosophical considerations is going to keep creating problems. By narrowing down the
focus and ambition of the CHC it may be possible to provide better coherence to value
system and bring down number of values to be universalised within the organisation,
astly, it must be kept in mind that all values cannot be and should not be legislated as
rules within the organisation. Just as some people call laws as minimum ethics, the rules
o t e organisation should also be looked at as minimum value or onlv those values
necessary to be universalised for the socially useful and efficient functioning of the
organisation. The rest should be left to the commitment and goodness of individuals.
14
(B) ORGANISATIONAL STRUCTURE
The factor of structure is very important in keeping organisation alive to newer
challenges, impersonalise it by making it a public space and by ensuring a system of
participation. My first glance impression of the structure was that it was very weak and
traditional. Later, my detailed examination of it only provided confirmation of my
feeling. It is not surprising that unconventional thinking and work by NGOs in our
country are often carried out in an organisational structure that is very conventional. But
this produces imbalance and keep creating its own crisis. So one needs to pay more
attention to the structure and be innovative in evolving something more appropriate to the
work for which the organisation is created.
Another important fact is the organisational processes, and there is dynamic relationship
between the structure and processes. Those who do not see structure and processes as
inter-dependent, normally pay more attention to processes rather than structures. Besides,
structures would be virtually empty and useless if there are not good processes to make
them workable. The problem with the emphasis on the processes without structures is that
they could appear and get perceived more as top-down, benevolent and paternalistic. The
structures with good processes help in making the power-relationship explicit and good
structures could help in distributing power in such a way that it allows more initiative and
development of new leadership or political voice.
The organisational structure of the SOCHARA/CHC is very simple and based on the
legal requirement of the society. In that sense the organisational decision making
structure is basically that of society rather than CHC. The general body of SOCHAKA
elects the executive committee and the secretary to the executive committee also works
as coordinator/director of the CHC, the functional unit of the SOCHARA. Since within
the CHC the structure is only around the job designation or position accorded to each
staff member, the participatory functioning and participatory decision-making are left to
the processes sustained through coordinator’s initiative.
General Body:
All members of the SOCHARA constitute the General Body. It has 34 members. For last
few years the SOCHARA has been making lots of efforts to expand its number by
motivating individuals to join the society. The membership appears to be drawn from
three constituencies. The first one is its core-constituency made up of those who ha\ e
been associated with the society from its inception or for very long time. The second
constituency from where members are drawn are the peer and network groups, the long
time supporters and participants in the training and other programmes. The third section
is made up of the former CHC staff members, trainees, associates and others.
15
The annua general body meeting of the society, as compared to the number of members
how that he abend A
a' 1351
°f the annUal 8eneral body
of 7 to 10 indiv H inhe T5 m 60% t0 30% °f the tOtal membership. The core team
the resnon "bihtv a3 V
t'11 C°nS1Stent in attendln8 the meetings and also in sharing
could hZ h y
Executive Committee members. This consistent low attendance
could have been one reason why the SOCHARA tried to recruit more individuals in its
general body as members in last few years. However, the attendance has not7mp^
The efforts to get more people involved and take responsibility in running the society are
getting fresheVbToyodOlndSatlOn-ihere
°ne needs t0 “ in terms of
mitiflt8 f H 6 Td
d nCW ldeaS- However, it needs to be kept in mind that such
atI^cs must be well planned and membership offer should be based on mutual
S' 2^Pf Clatir °fh the responsibility for be'n8 a member. Besides, in a
activities i wi l he PeOplt,WhO arC |Otherwise very busy in their own profession and
activities, it will be impossible to find a time convenient to all for the meeting So a
airbus dywoulddberOVldh h
meetmgS 3t the convenience of
and not able i » ?
better t0 °Ok f°r rePlacement of members who are retiring
accepted only on the' m°re
and the new entrant’s membership must b^
accepted only on the promise of discharging some minimum responsibility.
SOCHARA/CHCre
f°r exercislng cauti°n in expansion of membership. The
undertake^as^nart^f t aCtlV1St-^^^^nS’ though some amount of activism they
wbh Sll t
Pu
?ir actlvlties- They are essentially institutions or establishments
leas^ moveTble0
Jake’.hlgh budget raised through grants and stakes in terms of at
east moveable properties, instruments, books and so on. Add to that an impressive
eJiXveX' hT'5 °,f "“C F°r SUCh es,aWish”»"' i' » necessary to ensure that its
hief governing body is trim, active and involved. There are also examples - several of
taten oveTbv the
^t'3 ~
estab,ishments run by societies have been
by the members who made slow but deliberate entry.
Thus’ tbose members not meeting minimum requirement of discharging responsibilities
Should be allowed to drop out and the entry may be restricted to only lose Z make
commitment to provide minimum inputs in the society’s work.
Executive Committee:
I he executive committee is the real day-to-day decision making body It is exclusively
made up of the members of the SOCHARA elected on this body at L AGM and h;L
enure of three years. With strength of seven members, it is natural that a big majority of
the core and regular members of the SOCHARA work as EC members.
memblf^nL^ScHAR a
1S fairly 8°od showingthat the core-regular
members of the SOCHARA are deeply interested in the work and welfare of the CHC
16
and all other activities of the society. Second, the frequency of the meetings is as per the
legal requirements. Minimum two meetings in a year do take place, in a few years the
maximum number of the EC meetings is four. Three, the minutes of the meetings show
that EC carries out a wide range of decision-making. It decides on all major policy issues
related to the work of the CHC and the SOCHARA, receives reports of work carried out
the CHC and takes decision on it; and at the lower level takes or ratifies decisions on
simple administrative matters like sanction of rejection of leave application and other
problems. Between two meetings, the secretary, who also works as the coordinator of the
CHC, is empowered to take decisions on the routine matters and also take initiative, with
the aid of staff and others, new activities; but the same are reported at the EC, discussed
and ratified.
The EC as a decision making structure in the period between the General Body meetings
seems to have worked well for the SOCHARA. The general acceptance of it in the staff
of the CHC has something to do with the processes in which care is often taken to invite
staff members for discussion during the EC meetings. At the same time in my discussion
with a cross section of the staff and former staff members about it in last five years has
elicited some responses that need to be addressed to. The administrative staff has been
finding itself in some disarray of late because of the sense of insecurity generated by the
uncertain future of the organisation or due to discussion on the re-organisation.
Somehow, the message from the EC has not been clear enough to allay some of the
problems of theirs or they are not able to articulate their problems or they are finding
themselves not fully competent to the new tasks coming in the way. My collective
discussion with them could not generate enough material to pin point the problems except
a statement saying that they are not trusted enough, but their problems, if they are
significant, are worth looking at. In any case more needs to be done to tackle this issue of
trust as it has been articulate.
Some of the former staff members have also raised issues related to the considerations
that go in making certain decisions. The former professional staff also aired some similar
issues. One area they showed lots of concern was that criteria used for judging their
competence and contribution. For instance, at least two former staff members said that
one the reasons they left was related to non-appreciation of their competence to represent
organisation in meetings, particularly national and international meetings. They also
raised issue that such decisions normally favoured the SOCHARA members for
representing the organisation while they were actually working on the subject on which
such meetings took place.
The critical remarks on the decision making process throw some light on the need to
work out a structure that has formal representation of the CHC staff and at least
strengthening the inter-phase between the SOCHARA and the staff. This issue will keep
becoming critical as the CHC expands its activities (as it is doing now) and more
professional staff keeps joining.
17
The CHC Staff:
There are several structural and functional issues related to the staff raised by individuals
I interviewed. Most of these issues take into consideration only last five-years as they
seem to have come more forcefully with the expansion of the project based activities and
community health training.
Two issues discussed above are found to be important. (1) The issues of formal
representation of the staff in decision-making process to ensure that there is wider clarity
and understanding of the decisions among the staff. This does not mean that informal
processes of the consultation with the staff are weak, on the contrary, they are very much
there and consultations and their democratic nature are acknowledged by most, but that
has not overcome the uneasy feeling about that decisions and the justification for
decisions taken. It might help to formalise those processes so that participation does not
look selective. (2) Structurally it is important to demarcate the areas of direct
involvement of SOCHARA members in the work of the CHC and the areas where the
CHC-staff has full autonomy to represent organisation (CHC and not the SOCHARA)
and autonomy to design and undertake activities. This demarcation should go hand-inhand with the strengthening of the inter-phase between the SOCHARA and the CHC so
that there is a formal forum for interaction and resolution of problems cropping up.
Other issues raised in interviews are as follows:
(a) Some of the former senior, professional staff has found the designations used
problematic. The designation as Fellow was found to be less useful while working with
the outside organisations and they felt that better designations are needed so that they
could help them in facilitating their work.
(b) The issue of right mix between the project work and general work underpinned some
of the discussion. While nobody opposed the idea that project staff should also be
undertaking other works, there was some amount of disquiet on how that could be
achieved. Issues like the projects also flowing from the core concerns of the organisation,
the mix should not be looked at administratively in terms of number of hours put in for
each activity but in terms of the extent to work put in on the topic of the project beyond
the work committed in the project proposal, how and who decides the work that is
project-based and general, etc were mentioned. This does demand not only some clarity
but also consensus among the staff.
(c) An indirect mention of the way projects are formulated and their connection to the
overall plan of organisation development made both by some SOCHARA members, peergroups members and present and former staff. A muted concern whether the project
would be taken on the basis of availability of money from the funders or they would be
evolved as a part of the raising funds for the short and medium term activities planned
was also raised.
18
(d) Several people raised the issue of second-line leadership and lamented on the
structures not being conducive to development of such persons. A few were outright
looking for motives for “not allowing second-line of leadership to develop”, while all
others (big majority) were more understanding about the problems of developing and
retaining second-line of leadership in the NGOs but wanted more reforms to ensure that
such leadership develops at the earliest time. Interestingly both the groups generally were
of the opinion that such leadership would evolve only through better planning,
positioning of individuals in the organisation, provision of autonomy in work and more
tolerance to different ways of doing things. The former on the other hand articulated need
for more institutionalisation, representation in decision-making, professional approach to
work and better salary structure to retain emerging new leaders, the latter group was more
reticent in talking about such issues but wanted such second line to develop by paying
extra attention to the task within the existing structures.
(e) The coordinator has decision-making powers between two EC meetings, and some of
the major decisions by the coordinator are reported to the EC, discussed and ratified.
Much of the criticism on the decision-making of the coordinator reported was related to
the style of functioning, and so comparison between the past and present coordinator,
were at that level. While I did suspect some motives in some of the responses particularly those that made comparisons, I chose not to confront but accept them at the
face value as it is always very difficult to have individuals with same style. At least one
former professional staff while airing criticism of style, on his own admitted to the
humility and transparency, thus dismissing the ideas of motives. My inference is that
much of such criticism came because of three reasons: (1) the tension between direct
organisational commitment and desire for autonomy at the level of work, (2) inadequate
appreciation of the deadlines for completing tasks and accountability to the funders, and
(3) strong disapproval of quick administrative measures without allowing the process of
negotiation on the problem at hand. Structurally, one of the ways to reduce (they can
never be fully stopped) such problems related to style is to have a small formal
committee of drawn from the staff to assist the coordinator so that such tricky decision as
wider support within the staff and at the same time the coordinator retains both the veto
power as well as emergency power to make decisions.
My own feeling while going through responses on the organisational structure is that the
complexity of the evolving work and organisation demands more formal involvement of
the staff in the management of the organisation, more frequent meetings of the EC or the
EC to act like a governing board and devolves the day to day executive powers to the
coordinator with a staff committee to assist in the process. The minutes of the regular
meetings of the committee could provide better insight to the EC about prioritising its
intervention. This process could be a beginning of both more thinking in the SOCHARACHC relationship on the managing the staff-based organisation and promotion of the
principles of participatory and self-management at the level of CHC. This would provide
a meeting ground between progressive staff policies (rules and salaries) with the
19
commilmenl and polltaT con”'ousnesPr°Vi<ie
al'e"m'nl belw“" die demand
of
problems of „„rking as emo ZT “"™8 ““ SBff frOm ,he SOCHARA and
0p'ra,i»"adsedobjee1ivesanddecisLso”heZcSXa,l°" Wh°S'
“ to
Rules, Salary scales and financial position:
The rules and regulation governing the CHC are f ’ '
fairly elaborate and cover most of the
._./s - making provision for
person fromTheNGO made^ITmment thltTh51 °f
community-based NGOs. One
out about a couple of years back
A.Sa1^ revision was carried
Philosophy and values system seolZ'm'' aS '"fo”'*' “ 'he disc“ssi°" i" >he
commilmenl Io equity and (he salary exoekaZ ‘r defi"ll'ly a M"slon between the
resulted into loss of some professionals *?nS 5 the Senior professionals-and that has
professional is about Znarity
'
'T™ men,i°'Kd
’ fo™er
professionals and ntediealUlZeal.h nZsZTZ6''™'" ,he !«lal science
individuals, is between thePlowering of sal eSS,Ona S'. Thlrd tension’ rePorted by two
“market value” while giving salary that i
7
thUS pay‘n8 them less than
in order to meet the value of equity The fo^thten11311
Va'Ue” t0 l0Wer leVel Staff
but implicitly present (and found to be a tensh
n°! mentloned by any respondent
for those who involve themselves in comm
t”
NGOs^ ls between emolument
and higher levels of training. The last 3^.2 7 t "3 "2 th°Se who do research
most difficult to resolve and that is the maT^V^
the action-research, are the
are not able to build good tradition of '
actlon/comi™nity based NGOs
and the research NGoS
‘o^ableretain,ng g0°d research^
eommunity workers without violatine nrine'7°Vfde 306 °f pnde t0 actl0ri oriented
dilemma.
8 P nciPle of equity. There is no easy way out of the
to work at relatively low safary (less than “ma
Y ?,™ltted Professionals ready
UGC scales of associate and full professors) it has
2 2
.labour' or less than
The supplementary ways in which relatively’Io
1 rUg8 ed f0 retain good researchers,
are providing them more autoLm^rani care ^h’5
reta,nmg them’
possibility of becoming coordinator of fhP
• deveIoPment and high profile,
private consultancy outside office hours ( Or8anisat’on’ allowing them to undertake
allowing fiUl benefits), and so on
organisation or by
satisfaction and other non-material
mak'ng II Possible for them to have higher job
working extra in'prTvaT^TTheyTeed
which such strategies and other inno^afive st 2
understand the extent to
value system of the organisation.
trategies thought of are compatible with the
20
The financial condition of the society is in very good health. I had an opportunity tq study
the balance sheet of the organisation for the years 1999-2000 to 2002-3. The annual
income of the organisation more than doubled in this period and number of activities for
which funds are utilised has shown steady increase. I have not studied the books of
accounts but based on the auditor’s report and the details given in the balance sheets I
feel that management of ftinds is done in a fairly good manner. There is no doubt that the
CHC as an organisation has established a good financial base to take off in case it wants
to make a transition to a more complex institution.
Other issues of structure and policies
One former senior staff member expressed very strong feelings on the organisational
and staff policies, particularly with regard to the professional staff. According to him.
organisationally the CHC had become: (a) a nursery centre for fresh medicine graduates
J0IIi “plore the field of community health as a possible career, (b) a sabbatical centre for
ighly qualified professionals when they are on sabbatical period from the parent
institutions for very short period of 6 months to 2 years, (c) Post disaster make-shift
shelter for professionals who quit their jobs or had to shift to Bangalore due to untoward
professiona/personal distress, and they join CHC until they find alternative, and (d)
Professmnal vruddhashram centre, as a good retreat centre (retired men’s paradise)
rehabilitating 60+ yrs retired professionals. I was not able to separate out humour from
the serious point on my own, but soon I realised that this was a serious point as he went
on giving few examples in each category to buttress his argument. Essentially he was
arguing that there was too much reliance on stop-gap arrangements rather than building
core pro esstona group within CHC; and was arguing for development of an institution
a provi ed opportunity to professionals both for doing something socially good as well
as develop their career within the CHC.
( ) In the appreciation of organisation, the personalities cannot be kept out because thev
both shape the organisation and provide it with public profile. More so in the case of the
CHC as for outsiders, it has somehow got identified with Ravi and Thelma for very lono
uhlS,despite the fact that th£y
taken sabbatical for considerably long time
’j9°S' 1 has ‘ots of difficulties during the interviews to separate out points made on the
HC as organisation and on both or one of them. As far as possible, I did ask for
clarification but it was not possible always. When such clarification was sought I had
found that the issue pertained more to the individual than to the organisation or it was
assumed that both were same. While this is not surprising, it makes simple issues more
delicate than they ought to be. On the other hand, some of the respondents very forthright
in making some strong comment on the place of Ravi and Thelma in the CHC This was
also natural because an association of such a long time was bound to personalise the
place and the image of it. With that explanation, few strong points made are worth
mentioning so that in future planning of the organisation they are kept in mind. Six out of
all individuals interviewed (included three former staff members and three others) felt
rather strongly that the CHC was a family affair and others had only temporary place
21
there. There was also an indirect mention by a few others in terms of availability of
public space within the CHC. At another level, several respondents positively
appreciated (three even saying that they idealise them) Ravi and Thelma but wereTiighly
concerned about the future of the CHC if they burnt out, or decided to do something else.
Such individuals usually also felt that for the sake of future, the SOCHARA should take
the path of institutionalisation — as one respondent put it, “it is inhuman to keep expecting
them doing the kind of work they have done in last 20 years”. They felt that only
institutionalisation could motivate some professionals to stay with the CHC for longer
time and thus relieve Ravi and Thelma from all responsibility. Three of the six
respondents who saw CHC as family affair imputed different kind of motives for not
institutionalising; such as they were insecure, they could not work with equals, and so on.
(3) Although there is no evidence that the SOCHARA/CHC have connection to the
church or Church-based organisations, or that its policies and work have anything to do
with religious activities, several persons, including a few members of the SOCHARA,
talked about their unease or just mentioned that it had some Church connections.
However, none questioned its secular credentials and did not make allegations on
religious lines. The major concern shown was about the narrow-base such orientation was
providing to the organisation. Yet, in my assessment of the work of the CHC and the
number of people inspired and motivated by the CHC show that its base is much wider at
national level. Perhaps their concern is about its direct interaction and network at the
local level - Bangalore and rural Karnataka.
(C) STRENGTHS AND WEAKNESSES
My notes on the interviews provide a very lengthy list of strength and weaknesses. I
suspect that I was told more about weaknesses than the strength because — as one person
put it - it will be easy for you to put together strength because generally CHC has an
excellent history, but there is less critical reflection on weaknesses as not many would be
ready to be very frank about them or they just do not want to hurt”. On the other hand, for
each response on strength I found another response that characterised it either as
weakness or recent erosion of the strength. As a consequence, it was not possible to
separate out strength from the weaknesses and vice versa. In a way I felt that this was a
much better situation, as it is not possible to look at anything in terms of only positive
and negative, but identify positive as well as negative in each aspect of the work of
organisation. Thus, given below are the issues raised and the range of responses
characterising them as strength or weakness in a dynamic manner.
(1) The most important strength highlighted very frequently is its long tract record of
work of last 20 years. Even those who left the organisation acknowledge the commitment
and sincerity of the CHC though they have other criticisms of the organisation. This tract
record, its survival of two decades, the amount of inspiration it has provided to
individuals and organisations, the support - both moral, intellectual and material - it has
22
provided to otherwise weak movements within health sector, the interaction and
networking it has promoted, made more and more people to look at the social aspects of
health, the advocacy it has done on some crucial issues, the good will and respect it has
gained in the circles of activists as well as policy makers, and so on — the list is too long
to mention — have given the CHC a national profile and prominence. An overwhelming
majority of the persons interviewed and those who responded to a questionnaire,
including its critic, described this as the biggest strength of CHC, and a base and potential
on which the organisation can embark on its next phase of development.
(2) The documentation centre was seen as strength as well as weakness - strength in the
sense that it provides very valuable source, particularly on movements and works of
NGOs, but weak because it looks frozen in time and not having adequate dynamism of
development. There were several suggestions for its further development from the staff in
charge as well as from others who have used it in the past. All of them said that it was an
excellent based for developing it and making its material widely available by using the
dissemination technologies like SOCHARA’s website.
(3) Excellent place to be for the “starters”, those who need basic understanding and
motivation. It not only inspires, but gives lots of ideas about what they could do in their
work. Several of those who have been inspired by it told that they have been using their
learning in their professional work. But some respondents attached a rider attached to it:
that one grows over it fast once the basics are learnt, and despite getting inspiration from
it they would not like to work there. One respondent said that there is some amount of
paternalism and he liked it very much in the beginning, but thereafter found it difficult.
Despite such criticism aired very forcefully or as a side remark, there was a general
consensus that the CHC has done its work as catalyst and motivator the best, and almost
all of them attributed it to the personality of and capacity to stir critical thinking by Ravi
and Thelma. In many ways the respondents attributed this strength to individuals rather
than to the organisation - a few even going to the extent that these individuals will keep
doing so irrespective of the existence of the CHC. The flip side of this strength was that
there was better appreciation of it by those who gained by “passing through” CHC, bv
collaborating with it from outside as consultant or as a part of team engaged in some
exciting programme or project, than by those who actually worked for some time there.
Other reasons given for not feeling like working there were that they did not have
capacity to be motivator, it was not an institution where professional contribution would
be appreciated, it was too demanding in terms of commitment while they could go only to
a limited extent in that direction (one said that its value system is “too harsh and rigid")
and so on. Only one of the individuals at the periphery of the CHC said that he would not
mind working for some time as staff in the organisation.
(4) Community orientation of the first several years was mentioned as the strength but
some others were feeling concerned about reduction in the community orientation in last
few years. Interestingly, those who felt that the. future of CHC was in undertaking more
research and policy advocacy did not mention much about the reduction in communitv
23
orientation but those who felt that it should go back to the original work of training of
GOs were emphatic in saying that the direct work with the community has suffered,
he some respondent with the latter view went to the extent saying that the NGOs that
were close to the CHC have moved away though not broken away from it, the change
was dictated more by the change in the orientation of the leadership - read, Ravi and
lhelma than the change in the priority at the ground level. They also felt that the
current priorities are gradually turning its strength in community work into weakness
This group suggested that CHC should opt for a mix of consistent community work and
institutional development, and should have less concern for organising “events” than
actually forging alliance based on common work.
(5) Lack of administrative and programmatic decentralisation. Everything is lump
together as one whole and as a consequence there is less initiative from below, the
divismn of labour is nebulous and not open to specialisation. There is 1
fKx,
+ 11 • 1- • 1 .
'r------- r------ —anviv io less sensitivity to
the fact that all individuals may
for all
all activities,
may not
not have
have enthusiasm
enthusiasm for
activities, or they are
attracted to a part and not the whole. On probing, I was told that there is some degree of
division of labour and specialisation already there but there is a tension related to
accepting as a correct process - there is constant looking back about the desirability of
such development thus making it very tentative and not allowing it to settle down. Alone
with this there was a concern for taking too many issues - the desire to respond to as
many requests as possible rather than focusing on the programmes at hand and doing best
in a focused manner.
&
On the administrative part, some members of the SOCHARA and some of the trainee
fellows felt that it relies too much on “inspiration” and “individual motivation” and thev
opined that as organisation grows, that is bit difficult to sustain - leads to some
unevenness in administrative management. Some suggested more formalisation of
management; others suggested weeding out of “bad” management practices. By “bad”
they mainly meant practices that curb autonomy of the professional staff, some
participation of the staff in decision-making, and some decentralisation at the team level.
(6) There was lots of appreciation of the work of networking. Almost all felt that such
networking initiative of so many years was a real plus point, and it has made manv
organisations conscious about their need to do work in the field of community health. At
he same time they and others felt that networking on the long-term basis would yield
etter dividends if the networking is combined with three important “in-house” functions
or works, viz (a) capacity building within the staff of the CHC, (b) some outstanding
ou puts from the CHC staff, and (c) CHC having its own field area of work. They felt that
by networking the CHC had contributed a lot, but beyond a point its moral authority in
le networ was non sustainable if it did not have its own development and team of staff
that is seen to be good work of its own. Two former senior staff members felt that
excessive networking sometimes made the leadership ignore the in-house capacity
available, it also made them to take less risk with the in-house staff by giving them
opportunity to make mistakes and learn. Another respondent felt that intellectual and
24
moral aulhorily of the CHC in such,network came from only a couple of CHC persons
(
i and Thelma) and so the organisation was appreciated less than the individuals In
their absence, the networks did not take others representing the CHC so ser ou iv and thm
was frustrating for the staff And such professional staff needed dme and pace “com
out with their own out puts before they were recognised in their ow right
«npfa¥W'±1Lk“f';7,aBiCUla,ed by S'V<!ral individuals - former staff and others al
by the CHc7rthe rask fo'
"P go“d ,”i,iativ's F”
the contribution made
y me CHC in the task force report of Karnataka was highly appreciated but at the same
.me no. doing enough to follow up its miplemenLon" "ndeig ’its
ndependent pokey research and using other advocacy opportumfes Hike medra^
semrnara, conferences, legislative assembly questions etc" wifo such dlra t-as
inSveTftom taNGO^'T
°f
P“P'e
" paM “veral
8“d
mtiatives from the NGO sector have not achieved desired goal because of lack nf
tgener.3
PI’essure f°r implementation - “comparatively easy to change policy difficult
ort r'XTcHC fS°
t0
dOne
the ^plemenfatiTn O^e sf^n
.omp I
m ?HC frOm he Per‘Phery (who also expressed his desire to work there
in the med a''hat CHC
^mnataka health policy work, somehow an image is created
our pohcv be to^WuheZ Z
W1‘h
g0Vernment’ and he recommended that
d Pk n
” it 1
T hard (for inade(Iuate implementation) and yet getting our things
and cone. T me alS°
CHC Was great initiator
-t so good m sustSg
and concluding the initiatives. The attributed this to insufficient attention to or Mures m
organisational development and in-house team building.
“CHC’MdS^'Ts 77 COnCemed ab°Ut thC f3Ct that there was no clarity on the
s mentity . Is it a campaign team, a scientific team- a platform for few
M in hoauseOhan OrganlSation/institntion?” Here too the emphasis was on what the CHC
did in-house being as important as what it did outside.
Tan I^erehigh appreciation of the contribution made by the CHC in building
Jan Swasthya Abh.yan, People’s Health Movement secretariat, International LetwoS
and campaigns, its role in People’s Health Assembly, its media profilingMe PHM and
so om One person described such contribution as “simply great”. Generally the Miteg
However' thiTworkofllst'f Stiengthe”ln8 such movements, particularly PHA and PHM.
.u .
.thlS WOrk of last few years has also attracted some criticism - four persons felt
that CHC has become
J more international oriented and thus neglected work in Karnataka
and India.
(10) I met individuals connected to environment and disaster management movements
contribSSe b tteCHC T'd
high aPPreciation of ^e
that thpQPdemanded
moreissues,
such work
from the CHC so
bU“dand
-Kb
i„ psevi^eX
”
25
(D) PROGRAMMES AND IMPACT - CONTRIBUTION OF THE
CHC/SOCHARA IN VARIOUS FIELDS. IMPACT
Many of the major responses about CHC/SOCHARA’s impact have been covered in the
i ical remarks on the its strengths and weaknesses. It must be re-emphasised that most
of the respondents were very clear about its general impact. The different or crk cZ
w-e “sua ly w.th regard to the extent or degree of impact. Some kej? cndcisms"
the °n r6 aSS,ertl°n
the imPact was great! but its organisational capacity to sustain
the impact in order to affect a major or long-term change was limited.
ttl^tlduals'and011
iSSUeS’tHe environment and disaster management, I could meet
way'll^e^onfribuhonOofZeScHC5
C0U'd get firSt hand information on the
way the contribution of the CHC was appreciated. The third category of work was on the
dammk
C°U d meCt lndlviduaIs from three NGO or NGO-networks who
unS On
P°S",Ve “pact °f CHC’S
>he capaci,, 2din, fo°
agenda
h™"!' dt1111
as non-health NGOs
a"d
bnn'”g c0,nl"unit>' health
their priority
'rain'”8 h‘S he'Ped bMl’,h' beakh NGOs »s '"ll
coZmlv0 leCvei°fJ{or understanding impact is based on meeting some
TntP
orkers of another NGO collaborating with the CHC project
Interes ingly, the project work of the CHC on different issues taken up in last few years is
rma y one in collaboration with some community-based NGOs usually not having
heakh as its priority area of work. The CHC does not believe in ^sUbSing its Zn
communitZeTelNGO Th^ bel'e,VeS 'n domg 11 in Partnership with an established
duration of LTf
T°V
m With g°Od baSe for intervention and reduces
capacities o L
“ Z organisati°n and at the same time helps in building
comm ni even'ZTheVHC
' 80,ng t0
'tS W°rk in
k
•
, ,
“ CHC Project gets over- 1 met community level workers
well eZblZe^'and thCHC
"‘“b0*
f°Und that the Partnership was
well established and there was mutual trust. However, I also found that this limited the
it is required to^mZ tbetappr°ach and Strategy that CHC could take up as ultimately
NGOs
'mplement its project within the organisational constraints of the existing
number of°MvM T'
"" S0CHARA'CHC sen! on! a questionnaire to large
bwhe CHC s ' 1 o
S°me Of ,heir responses teslify " ' »>' ™P0«
} he LHC s work. Some relevant responses are given below:
Impact and recognition as a centre:
It is an important centre for community health in India”.
26
Despite ... bleak scenario of voluntary organisations, the CHC is an outstanding
example (having) continued to serve the PEOPLE’S sector in spite of considerable
dilficulties........ The CHC has played a seminal role in advocacy not only at the
people’s level, but also at the State, Central as well as International levels, especially
in the WHO. ... The CHC ..... now claims both national and international
recognition. Their efforts need greater acknowledgement and support”.
“CHC has been the most active group in critiquing and advocacy in medical
education.”
CHC has been able to create a platform .... to view health as a justice issues
provides opportunity to learn to integrate the social, economic issues with promotion
of health.
r
Has symbolized ... (as) an organization truly dedicated to taking up causes and
spreading awareness on public health issues and problems in our country
Over
the years has maintained its credibility and integrity and therefore
lay-persons
have been able to use information, views, messages on issues, expressed by CHC with complete confidence.
CHC has documented effectively in a number of areas
has raised its voice on
many issues to be heard.
The follow through has not been focused enough to
produced specific results.
Appears to be capable of being India’s best advocacy
organization, yet is involved in too many areas to produce effective results.
I trust CHC to represent my/our concerns when it works at policy level or at a global
level. ... it epitomises a belief that you don’t have to become big to do something
big. And that professionalism has to be maintained even at NGO level
Its
greatest strength lies in preventing people from feeling threatened in a network their networking skills are excellent.
CHC counter balances the commercial iaspects of community health. ... gives a
forum to people who view health through
~ 1 an alternative perspective and gives them
opportunities to prove their point of view
provides some ethical values to people
Its contribution to the other NGOs
If could achieve something to promote community health (in my organisation), it
was mainly due to the contributioin from CHC and all those connected with it. The
very concept of community health was emerged with the support of CHC.
CHC was almost like a ready
i
recknor for the latest on medical or community health
information
Showed me the value of low cost teaching aids, especially the
posters and songs
CHC means “friends” who are always willing to help during
27
a training programme and to share their knowledge,
test new ideas.
.. a good sounding board to
Motivating and inspiring individuals
At the beginning CHC was a mentor. I was feeling lost in a new field and CHC was
able to show that values could be applied “even” in this (my) “speciality”
During
my post-graduate CHC was a senior friend and a colleague. One could rely on CHC
even when medical colleges and community health departments were getting
consistenta iSCd
CHC 1S
3 reference point ~ its attachment to ideals is
CHC has been an inspiration, calling me back to r*
my own commitment to people
especmUy those whoa re on the fringes of society. It has provided a’sounding'bolrd
tor my own doubts, questions, and search for ways to move forward in my path It
also been a partner in the wider effort to bring in values of cooperation, justice and
peace in our country / world.
J
has meant to me a refuge “a place to recharge” a place to visit when spirits are
down (but not out); to understand that “we are not alone” - that there are others who
also are constantly questioning, “trying to understand” fighting for rights for the
yojceless adding agendas if need be - but never “shying from the truth”. It has
also helped me to have faith in fellow human beings”.
CHC members provided me valuable mentorship and counselling. They helped
shape my understanding of community
interdisciplinary perspective on health and medlckie^ deVel°P 3 br°ad’ hollstlc>
The core team of CHC and many friends at CHC have been
a ‘landmine’ of shift in
my paradigm of thinking, viewing, believing and acting.
Community““ °PP<>r,"iV and help to
themsekes^hve3
inSPirati°n t0
«~ept of
PaSSi°n f°r helping people help
so had an opportunity to go through one independent review of the work of CHC in
nmZT611 S v3 h ^‘"'Hgfogramme (see Jandhyala Kameshwari, “An assessment of
p ogramme in Karnataka, 23 -28 February, 2001). The CHC acted a lead or nodal NGO
L oX NCO f 'I'0'1 StateSthat’ “G^erally the partnership between a nodal agency
and other NGOs has been seen in a positive light. All the partners felt that they have been
owed to retain their individual flavour in the implementation of the programme. By
and large the management and coordination of the programme has been smooth....... ”
28
Although there is no need to discuss the contribution made by the CHC in the‘Health
Task Force of Karnataka and in the drafting of its report as the same are well-known, it
must be noted that this intervention in the policy making at the state level was a
tremendous success in bringing about the impact of its work in last five years. This task
was carried out with lots of commitment and effort, and the individuals I interviewed
were highly impressed by the performance of the CHC in this field. Another work of the
CHC mentioned by respondent was on influencing the medical education at the health
sciences university of the state.
It must be noted that the study of the impact of work or programmes require more
rigorous efforts. One needs to go into each programme and not only look at how well
they were conducted by the CHC, but also examine its objective impact in improving
health or meeting other objectives and also how the recipients or beneficiaries
appreciated them. Such detailed examination of the programmes was not possible in this
review.
(E) QUALITY OF WORK UNDERTAKEN
I did not have time during the review process to objectively assess the quality of work in
the randomly selected programmes or projects. Indeed such assessment would be a task
in itself. Hence, this review does not have much - indeed almost nothing - in assessing
the quality of work undertaken by the CHC.
I indeed ask this question to many individuals I interviewed, particularly those who are
not directly involved in working at the CHC. The quality of these responses also did not
convince me to come to any reasonable conclusion about the quality. The responses were
varied but quite instructive:
The leading individuals are intellectually very good and whenever they have taken
up research-based work, the outcome has been excellent. There was high
appreciation of quality of such research-based writings. Some individuals expressed
disappointment that they have not done enough research, systematically published
their work in peer-reviewed, indexed journals nationally and internationally and thus
not done enough to influence the professional public health community.
A few individuals from NGOs where the CHC had organised trainings in the past
were interviewed and their general comment was very positive about the quality of
training. They showed more concern about the quality of follow up, as they
complained that CHC is taking so much work that it does not have sufficient time to
follow up.
29
Two types of critical comments were received on the quality of work in the
networks and the work at the community level. The first was that somehow there
was more orientation to number of events rather than what each everit was
achieving. Thus it needed more rigorous, high quality and clearly defined
intervention in the network related work. One person said that good networks cannot
be built by “flying in and flying out”. The second was that the CHC must strike
direct roots in some community, build some good work and experience in working
at the community level and do some demonstration of translating their ideals into
reality at micro-level. According to this view, such approach would take the quality
of their training one step ahead.
One person made comment that while lots of documentation of work was carried
out, but it is very excessive and not systematic. As a consequence, one does not find
systematically designed and regularly updated training manuals on some very
important subjects coming out of the CHC. He lamented that an organisation with
training at the high priority agenda should have gained good name by now in
providing such training manuals. However, he was quick to add that that did not
mean that trainings provided by the CHC were not of high standard but that it should
have done something more systematic to ensure that such training courses were
documented in manuals, thus providing much better guidance to trainers.
(F) FINANCIAL POSITION AND SUSTAINABILITY
As explained in the section on organisation, the financial position of the CHC has
considerably improved in last few years. It doubled its income in last three years and its
annual turn-our is about half a crore rupees. A concern was raised that much of the
income was from grants, and many such grants had come for specific projects, and that it
does not have enough money in its corpus funds and reserves. So there was also a
concern for its sustainability - with an assumption that if there is more annual budget, the
sustainability is more difficult.
I did not have detailed discussion on this with many individuals - not at all with anybody
on the financial statement of accounts of the SOCHARA, but with few individuals on the
issue of sustainability. So most of the points given below are my own comments.
(a) The excessive concern for the corpus funds should not be there as there are
organisations with less corpus funds and higher annual turnover than the SOCHARA’s
have been able to sustain themselves. Besides, with the low-interest rate regime in force
and with almost no chance of high interest rate times coming back, the income from the
interest of the corpus would be so low that one would need very big amount in the corpus
to earn adequate interest.
30
(b) Unlike in the past, there is relatively more emphasis on the monitoring and evaluation
by the funders and there is also more demand for focused work. The positive side of such
demands is that they force the NGO not to keep doing anything and everything that
comes in its way, but do better planning and have long term focused work. If such
situation is alright for the CHC, its capacity to attract fund is still very good.
(c) Several respondents made a strong plea that CHC should explore possibility of raising
funds from the public and private sector corporate houses and their philanthropic
organisations. In principle it should be possible to raise such funds if there is no
unacceptable strings attached to them. Particularly efforts need to be made for increasing
corpus funds or for getting endowments that could sustain some of its activities.
(d) Induction of competent professionals in the team would help in the fund raising too.
Firstly their presence would make the organisation more attractive for providing project
based work, and secondly these professionals in a course of time would be able to attract
funds for their own work.
(e) One viewpoint was that the CHC did not have to struggle too much so far for funds as
it had funders who were very committed to it and its requirement of funds was modest. It
also did not create non-moveable assets and thus remain somewhat tentative. This has,
according to this view, made the CHC somewhat less dynamic (lethargic) in fund raising.
It would be more dynamic in that field if it creates stakes in terms of non-moveable
properties (its own office building, for instance); and also has responsibility of supporting
a larger team of professionals. In fact, some amount of insecurity related to funds was
considered better situation than having it easily as that often robs away the organisation’s
dynamism.
(0 Since the turn over of the SOCHARA has considerably increased, there is a need to
develop some expertise in the management of finances. Gradually both in-house and
consultant-based expertise in finance management would be needed for efficient
utilisation and creation of reserve Funds created for various core activities by
accumulating surplus money in specific Funds.
In essence, organisational expansion — in terms of human power and work/activities —
bring about more responsibility at the level of finances. In the present context of dearth of
good NGOs, it is not impossible to sustain work of good NGO provided one plans well
for fund raising, focuses work in the key priority areas, professionalise its working and
give sufficient attention to the outputs and impacts.
31
DISCUSSION ON SOME CRUCIAL ISSUES OF PRIORITY IMPORTANCE
(1) CHANGING VALUE SYSTEM:
Two milestones - the registration of independent society in 1991 and the change in
direction in 1998 - are impacting in many ways the foundational philosophy and the
va ue system, and that is making some of the society members concerned. They are more
concerned because further consolidation of the course could lead to major change in the
foundational philosophy and the value system. This issue needs very explicit discussion
within the organisation. It is not sufficient to argue that the developments since 1991
have not seriously impacted the philosophy and the value system. The following points
need to be clear in the minds of the members - particularly those who are associated with
the organisation since its inception.
The period 1984-90 is cherished as “golden-age” because it was formative, idealistic and
the most dynamic phase. The 1991 change was supposed to formalise and integrate those
values and ethos in a formal and independent organisation. However, it seems that the
society gave less attention to, or needs to appreciate, the objective impact that the
formalised organisation brings on the value system and ethos.
First of all, the formalised legal system creates both stakes and responsibilities. Not just
individual s likes and dislikes, but the presence of organisation needs to be taken into
consideration more and more.
Second, there is pressure to expand the public space in the organisation and demarcate it
from the founding individuals’ private space.
Third, it inaugurates the institutionalisation of the organisation. I think this is hardest to
accept, because if, the founding philosophy and values are strongly against the
“institutionalisation”, or attaches premium on “de-institutionalising” just in the same way
as one attaches philosophical and political importance to “de-professionalisation”, “de
mystification , de-bureaucratisation” and so on, the organisation goes through a phase
of denial ( we are an organisation but not institution”, and a phase of accommodation
( we have institutionalised a bit but there is absolutely no change in our original
philosophy and value system”).
Fourth, it makes it urgent to rationally understand the relationship between the “society”
(SOCHARA) and its “functional unit” (CHC). I feel that this relationship is not as
seriously discussed as necessary. Often the society is seen as the upholder of the
philosophy and the value system. The functional unit, as its name suggests, is the one that
operationalises the practical decisions and carries the burden of living that philosophy
and the value system. 1 his does not mean that some of the society members do not get
32
involved in providing lead and direction, but that the essential burden of
operationalisation is collectively on the functional unit and not on the society.
Fifth, the establishment of the formalised unit brings into the relationship another force,
the paidj as well as honorary staff of the organisation. It is this group of people and the
■■■-’ they
work that remains at the centre of discussion on success and failure ot
way
1
implementing ideals. Despite all idealism, one needs to accept that once we have
employees, we become employers. For activists entering into the running of paid full
time organisation, it is very difficult to accept the reality of the employer-employee
relationship. Over and above that, it also brings about hierarchy. The most important
challenge for a sensitive voluntary organisation is not to strive for the utopian state of the
elimination of the hierarchy, but for how to have hierarchies without hierarchical
relationships.
I think it is necessary to look at this dynamic of development in order to understand the
stress that the original or founding philosophy and value system keep experiencing, f e
semantic of terms may not be useful because each one may define "institution .
“bureaucracy”, “hierarchy”, etc. differently. What is essential is the acceptance of the fact
that in the formalised paid organisational structure, they are present; the only thing that
we can do is to make efforts to give them different form, a more humanistic form. In the
relationship between the society and the functional unit, we need to pay attention to two
processes: (a) the functional unit should never be allowed to become the utilitarian
appendage of the legal unit, the society, and (b) put in place the formal structure and
processes of autonomy and empowerment for the functional unit(s) and the individuals
working there. Attention to these two aspects is important simply because the society and
the functional unit exist in power relationship and the society being a legally empowered
body, always has more power than the functional unit. The issue of ethics in the structure
of relationship needs to be addressed here.
It is often argued that certain values are eternal and must be upheld under an\
circumstance and organisational form. Here, we need to filter out the secular ethics from
the individual morality. The latter is important for each individual and it is bound to be
different for each depending upon the cultural, religious and other upbringings, but the
former is the one that deals with the standard of conduct in the secular and public space
and hence needs to be continuously contextualised. Moreover, we need to discuss this the
idea of comparing the present with the past. Why do we assume that the idea and
philosophy we started with ware qualitatively superior/better than what we have on the
ground today? Perhaps it makes better sense to understand evolution of the ideals simply
because there is always continuity of certain elements and the change in others. The
elements showing continuity are also not eternal, and simply because they survived do
not make them eternally ideal. A reason for that could be that they are kept alive
artificially, but have lost the actual base within a majority of the society members and the
staff. Those who have not survived should also not be seen as dispensable simply because
we may think them important to make practicable.
33
The only suggestion that I can give is that the SOCHARA/CHC need to have very hard
and realistic look at the philosophy and value system of the organisation. There is a
possibility that it may become an endless discussion, but that should not deter it to have
appreciation of the philosophy as it is presently practiced and not get carried away by the
philosophy as it is idealised.
(b) ORGANISATIONAL STRUCTURE AND PROCESSES
One of my strongest feelings is about the structure of the organisation. I narrated some
aspects havino
having bporina
bearing on the.
the structure in the orevious
previous point; here they are developed
further. Several issues need discussion:
First, the process of organisational change seems to have started in the CHC but not
reflected in the SOCHARA. This is a very paradoxical situation simply because the
changes introduced since 1998 in the CHC came from the decision of the SOCHARA.
Perhaps the members have not fully appreciated or understood the meaning of t e
changes. The change in the CHC is that since 1998 the process of institutionalisation and
professionalisation has been augmented. Correspondingly, there is little attention paicI to
the changing role of SOCHARA. We need to face the question - if the CHC
institutionalises or reaches a higher level of institutionalisation and professionalisation,
what would be the role of SOCHARA?
Second, the first two (1984-1990 and 1991-1998) phases of the organisational
development, the SOCHARA was a support network nurturing few individuals who had
made commitment to work differently, be a sounding board and generator of the ideas. In
many ways, much of the organisational work as against the programme-based work were
centred, around SOCHARA and the CHC was just a functional unit. This system has
continued even now, and to my understanding, one of the strongest criticisms of some o
those who worked in the CHC in last five years implicitly is in relation to this system.
This does not mean that there is absolutely no participatory system. On the contrary, most
of them did describe it as participatory system. However, the problems I found were more
with the content and context of participation, because participation does not automatically
lead to democratic and empowering system. So we need to discuss the participation an
decision making in the areas that matter, the areas that have formal power sharing
arrangements, rather than looking at the participation in formal sense and often in the
softer areas.
Three, the executive/managing committee of SOCHARA is by law and in effect should
function as the Board of Trust or Governing Board of the CHC and not as the executive
body. In a way a perusal of the minutes of the executive committee shows that it is in tact
moving in that direction but without discarding its executive functions and creating
legitimate and formal body of the staff to devolve those functions. It is absolutely
essential that the staff, by having circumscribed and devolved formal executive functions
34
learn to govern the organisation and learn to evolve its own development plan. Presendy
Sprocesses are there but at the informal plane, and that is making many mdividuals
tentative in committing themselves to the processes.
Four this would necessitate the demarcation of role/functions, powers and system of
accountability between the staff body, the coordinator, the executive commi tee as
governing body and the general body meeting. Given these structures, one would als
need the Meeting places - where they are able to jointly meet, consult each other and iron
out differences from time to time. I believe that the EC and the GBM
act as pohcy
making bodies, peer reviewers, sounding boards and refrain from directly exercis g
executive function unless absolutely essential or when there is a course correction
to be necessary.
Five the SOCHARA needs tighten its norms for membership and reconsider its ea
decision to increase numbers. It must be kept in mind that CHC is no longer a sma
organisation - its financial turn over has increased several times as compared to early' an
mid 1990s - and there are stakes involved. The current practice o
individuals in the SOCHARA if they cannot continue to be a part of the CHC must s p.
It must also overhaul its membership by keeping in mind those who are g™ely
- not in general as a part of network or ideology-sharing but specifically for the
CHC/SOCHARA - and those who share the vision for the future of the organisation.
Six, the CHC needs to be given a more systematic and formal shape. The CHC cannot. be
governed only using the rules and regulation of the society, but it also needs a separa
administrative rules and structures. I am sure that there are adra’nlStr"tlV;^‘evS’hS"1g
scales and other things existing as a part of the administrative orders adopted by the EC
from time to time. But this is not sufficient - they need to be brought tog^the^ °^nly
debated, modified and in consultation with the staff adopted jointly by the EC and
(c) INSTITUTIONALISATION:
The most intriguing aspect of the CHC/SOCHARA for over years for me has been its
concept of being facilitator and catalyst organisation and not being an institution, ha
made lots of efforts to understand this concept as applied to organisation but no
understood fully. So if my comments betray my ignorance, I beg apology in advance.
I received a very consistent (very few people doubting this aspect) response from all over
the country from those who associated with the CHC for short duration as a part of
network or visitor to the CHC, and then kept in touch and remained in active contact. A
of them told me about how they felt inspired, how they could get some vision and how
such association impacted their decision about involving themselves in communHy
health. However, some more discussion brought out several issues tha are-. worth
pondering about. First, there is a mixing up of the individual s personality and the
35
organisation. Some of these individuals were very appreciative of individuals but not so
much of the organisation. Particularly Ravi Narayan was identified as highly suitable
person as mentor, facilitator and the one who could provoke them, but not the
organisation as such. I know that individuals give shape to organisation and sb they
cannot be completely separated. But if the unevenness of the development between the
individual and the organisation keeps widening, the ups and downs, the changing
priorities etc of the individual can have sharp impact on the organisation. Secondly, it is
very evident that with the gradual withdrawal of Ravi Narayan, there is corresponding
change in the way the organisation is playing the role of the facilitation and being
catalyst. This is based on my conviction that any organisation, having basic dynamism
and social commitment, at some level acts as catalyst and facilitator. Thirdly, the
organisational role as facilitator often depends upon how professionally well it functions
in providing training, undertaking research and in advocacy. Its work on health policy
and research, have those components, but they are still under-developed. One of the
reasons for the under-development is that it is not able to find suitable and modified
organisational role as catalyst and facilitator; and stop looking back as more personalised
approach that was there in the informal phase of the development of organisation.
Fourth important issue to ponder over is the kind of needs and demands that are now
emanating from the NGOs/CBOs and public health bodies (including professional bodies
and medical colleges/university). In the 1980s and early 1990s the CHC was acting as a
catalyst and facilitator in a different social and political environment than is doing now.
From health as being community health activity - the paradigm shift that is well
documented by the CHC - it has acquired some additional meaning, one of them is the
also being a right and political process. The health as a right’s issue was not as prominent
earlier as it is now. Besides, the NGOs are undergoing rapid changes. The impact of
economic reforms on the NGOs is enormous. I have a feeling that the list of what is to be
catalysed and facilitated has expanded considerably and within that the socially relevant
research, the policy advocacy, monitoring implementation of policies and impacting
mainstream have emerged as newer areas having direct connection to the developmental
process.
3/)
WAY FORWARD
What is the best way forward for the CHC? Answer to this became more difficult as I
progressed in the review than I had anticipated at the time of starting the work. I am
giving here a very brief and tentative view, but it can be modified and elaborated in the
course of discussion with the SOCHARA/CHC in coming time. Besides, issues and ideas
expressed in the previous section - some in very provocative way - provide lots of
material for discussion and decision-making.
Three alternatives kept coming back in discussion: (a) Make a retreat, go back to pre1998-9 situation and continue doing what the CHC did between 1984 and 1998. The
recent changes are institutionalising the organisations, divorcing it from the community
work, making it more research oriented, expanding its strength and making it financially
non-sustainable, and so on. (b) Build on the great achievement of last 20 years, halfbaked institutionalisation has created more problems so it would be better to do
institutionalisation in the planned but bold way, preserve some of the values and ethos,
and chart a course towards establishment of a good community health institution, (c) The
CHC should be closed down.
The last position was not explicitly taken by anybody, but some individuals indirectly
mentioned such possibility. The factors that prompted such response were: (1)
institutionalisation would be a worst option than the closure, (2) unable to carry on
because the core team is tired, burnt out or has changed its direction.
So essentially the views largely revolve around the first two alternatives. The first
alternative was articulated by a minority of the informants while a big majority talked in
terms of institutionalisation.
My own view on the subject is very clear. I feel that institutionalisation is not only the
correct option but perhaps also the only practical option available. The only other
practical option is closure. The first option is not practical at all, as there is no core group
to undertake work in the manner required. The best way out would be go for
institutionalisation while making efforts to preserve as much of the values and ethos as
possible. While institutionalisation will add new priorities, it should also strive to
preserve in suitable form the present work of motivating and inspiring individuals and
NGOs to work in the field of community health and be committed to social paradigm.
I think the present initiative on the community health fellows, trained in the CHC and in
several community health NGOs in different parts of the country, has a great potential to
initiate systematic institutional work - training, research, community work - in people
oriented community health. Given its broad canvass and people-orientation, by making
one of the basic components of the institution, it will also help in preserving many values
and ethos so dear to the organisation. Such work will also help the CHC in bringing its
37
network partners to share the work - as it is already doing by placement of fellows in
different community health organisations.
Another area of high potential is development of systematic and rigorous research work the policy research, health system and operation research, and general social science and
public health research in health and health services. The socially relevant research with
high professional quality can give good support to the movements as movements can use
such material in their campaigns. The advocacy work based on such research could be
complement the efforts of the movements.
38
Organisational Reviews of
SOCHARA-2005Dr.Amar Jesanis Review
p
Xm '
Kx
Km*' Km* Km* Km* Km* Km* Km* Km* Km* Km* Km*
\>A
COMMUNITY HEALTH CELL
BANGALORE
REPORT OF THE REVIEW
Amar Jesani
Mumbai
2005
Km*
Kx Kx Kx Kx Km* Km* Km* Km* Km* Km* Km* Km* Km* Km* Km* Km* Km* Km*
TERMS OF REFERENCE
A team of two external persons were supposed to undertake this review, but one of them
could not join the team. Thus, with the cooperation of the team members drawn from the
SOCHARA, this review was completed.
The Terms of Reference for the review are very broad and all encompassing. Although
they provided free hand to reviewer, all issues in the terms of reference could not be
adequately dealt with in the review process. The Terms of Reference were as follows:
1. The philosophy in founding the Community Health Cell. The objectives at that time.
Modifications of the objectives - what, why, when? The present objectives. To what
extent have these objectives been achieved?
2. The organizational structure of the Society (CHC). Is this optimal to achieve the
objectives? Modifications, if any, needed to achieve the objectives better. Recruitment
of Staff, training and re-training. Staff development programmes and their usefulness.
Staff turnover, Staff satisfaction. Is the organization democratic / decentralized in its
functioning? Is there a system of planning, monitoring and evaluation of the functioning
of the Society and taking action on the findings?
3. Strengths, weaknesses, constraints and opportunities, Have the strengths and
opportunities been utilised to achieve the objectives? How have the constraints and
vveaknesses been reduced / overcome?
4. Values and life styles of the Society members and team. Did they have any impact on
the functioning of the Society and on other organizations / people? If yes, how?
5. Important programmes of the Society (CHC) and their impact - local, state, national,
international. Involvement of the Society in advocacy and networking with other
organizations - governmental and non-governmental; experiences and learnings from
them.
6. Quality assurance in the activities of the society. What are the procedures in place to
assure quality? What steps are needed to assure better quality?
7. Society (CHC) as a learning organization,
How has the Society (CHC) utilised its
programmes for learning by the members / staff and in creating awareness leading to
action among the people on the health related problems?
8. Comribudens of the Social, (CHC) to equity, soci.) justice, environ™™,.! .nd 8ender
3, miersecloral .cl,on, community organizudon, mobilization and participation and
empowering the people, especially the disadvantaged.
Of ',he Srie,y <CHC)‘b',owards he,1,h planni"B and
or
and vinXet
yes,^Xb'"aT‘,iV‘' Cr“iVe “n,,i“OnS
bj
<CHC>?
11. Education/training: what has been the i
involvement of the Society (CHC) in training
and education in Community Health? Public Health?
Is there a need for greater
involvement? If yes, how should this be done?
12. Management of finances of the
Society (CHC).
sustainability in the long run?
How can we ensure financial
13. Factors, which facilitated the Society (CHC)
to work as a team.
enhance teamwork.
LX“re"dati°”S f0' imP'0V':d SmC,iOnin8 Of ,he
Suggestions to
for new
The report is divided into the following sections:
•
•
Terms of Reference
Methodology
Findings pertaining to Terms of Reference and any other relevant observations
Discussion on some crucial issues in the priority concerns of the organisations
•
Suggestions for the way forward
Acknowledgement: My sincere thanks to all who cheerfully spared time to share with
me their experiences with and the views on the CHC, at my convenience. My thanks also
to the staff of the CHC who made my stay and travel in Bangalore comfortable.
METHODOLOGY:
1. The SOCHARA made available the documentation of last 20 years, starting from it
inception 1984. The documentation included reports and publications of the CHC, from
1991 onwards the minutes of the meetings of the SOCHARA and the executive
committee minutes, the financial information of last five years, the documents pertaining
to work plans, the previous review of 1990 and 1998, various writings related to the CHC
and its work, the newsletters of the CHC, rules and regulations of the society and so on.
All of them together run into over 1000 pages of documentation. The reviewer spent lots
of time going through the documents, though selectively, in order to get a fair idea of the
mission and history of the organisation.
2. An internal review of the CHC by the staff was undertaken between April and
November 2003 in
-i five meetings. A draft of the internal review report was made
available.
3. A mailed survey of opinion of members of the SOCHARA and associates; was
undertaken by Dr. Mohan Issac, president of the SOCHARA. 27 individuals responded to
this questionnaire. A summary of their responses was made available to the reviewer.
4. Starting from January 2004 at the World Social Forum, the reviewer conducted a series
of interviews with the individuals presently working at the CHC, those who have left the
organisation, those who associated with their work in some capacity, some of the
members of the SOCHARA, some individuals and organisations who have associated
with the CHC/SOCHARA from time to time in collaborative work and one meeting with
the Bangalore based field workers involved in field based project of the CHC. Totally
over 40 persons were interviewed, some of them in more than one sitting while some
were interviewed for only few minutes. Two were interviewed on email and telephone.
A brief note on my experience in the review process: A few important issues must be
put on record so that the findings and the over all report of the review is better
appreciated:
(a) I know CHC for last more than 20 years now. I have been its admirer and at the same
time, as it is my researcher’s temperament, its critic. One’s respect, personal friendship
with the leadtng group of
i„divi<toais, Mc cou|d become
o
assessment of the task at hand. 1 did feel some corfhet of inlemsts or to put it better
some amount of conihsion and tension, and emotional turmoil while doing this work h
often slowed me do™, and at least once made me to question myself the wisdom of
accepting this work.
(b) My work was made bit more diffieult by the faet that many of the infonnants or
respondents whom I interviewed were also known well to me, though not as well as Ravi
and Thelma are. They trusted me and tolerated my way of interviewing. I often became
very provocative, taking position of devil’s advocate in order to make the informant give
the best response on the topic. They mostly tolerated this, and gave me as frank
JnfoZf011
P0SSlble' ^°re
°nCe 1
t01d that
Some sensi«ve
nformation or view simply because they trusted me, or thought that at least I would bring
i make note of it in my report. I do not know how far I have succeeded in giving
representation to such points, but surely such information made me to work and think
overtime to judge about how to assess and interpret such information.
c) as y, noticed discrepancy in the responses given by individuals to me and in their
optmon given m writing to the organisation. This was partly due to the fact that in
personal dtscussion one tends to elaborate and explain better than in writing brief
responses to questions. But in four cases the there was major variation in the eonle
making me uneasy about what to use as authentic. Ultimately 1 decided to use the
information provided to me in interview or on email as authentic position of the
individuals and I have used the same in the report.
■ I IIUNUII I II
FINDINGS IN RELATION TO TERMS OF REFERENCE
(A) PHILOSOPHY AND VALUE SYSTEM OF THE ORGANISATION, VALUE
AND LIFE STYLE OF MEMBERS:
These aspects of the CHC/SOCHARA are considered to be its greatest strength. On
scanning through the documents from the very inception of the organisation, there is
constant explicit commitment to certain type of the organisational philosophy and the
value system. Under the rubric of philosophy and value system one finds several things
mentioned. The philosophical understanding of voluntarism and its necessity, the way
one looks at the health issues - the social paradigm of health, the appreciation and faith in
collective community actions, participatory way of functioning, non-hierarchical
relationship, commitment to equity and empowerment, and so on. My first discovery
while interacting with many individuals during the review was that these terms were used
by most of them, but their meaning was understood differently or not understood at all. A
part of the problem is that these terms are very general, with omnibus meanings.
Voluntarism, participation, non-hierarchical relationships etc. need rigorous
discussion and consensus development on how they are operationalised in the
CHC’s internal functioning, work and in its relationship with other organisation.
Keeping this in mind, I probed only few elements of philosophy as they were viewed as
well as perception of their actual operation at the organisational level.
Voluntarism:
I got different meaning of voluntarism from the SOCHARA members who are not
working in the CHC than those individuals who work or worked in the past as full time
staff. This was in a way natural and found so in many NGOs. The SOCHARA members
are either professionals involved in their own work or come from more institutionalised
NGO background or are retired from some such work. On the other hand are those staff
members of the CHC, who are not or were never a part of the SOCHARA. With a few
from each category I had some discussion on this aspect, with the rest such issues came
up by chance or I was enlightened indirectly.
I could discern three levels of understanding of the voluntarism. The first level was more
at the individual level, wherein I was told why it was necessary to get involved in some
voluntary activity while being engaged in one’s own mainstream work. The justification
for that ranged from religious to simple need to derive satisfaction and give back
something extra to the society. At this level, there was deeper commitment to the
individual morality. The second level was more political, and associated it with the need
for social change. The voluntarism was to undertake activities, both professional and
political, that could lead to some impact on changing, for better, the lives of the deprived.
And third level was more pragmatic, and looked at the voluntarism as a part of more
satisfying career choice. At this level the responses ranged from the idea of assisting
those who were doing good work, to attraction for involving in organisation that was not
bureaucratic, allowing some initiative and experimentation of new ideas. No individual
responded only at one level, all of them used points that partially overlapped at least with
one more level. Interestingly, one relatively new staff member felt very sad that in the
NGO sector the staff were becoming more of full time functionaries and losing their spirit
of voluntarism. The voluntarism as non-remunerative, altruistic and purposive action
came more from those who did not depend upon the CHC for their basic survival or who
had other sources of income.
At another level, there appeared to be some amount of conflict between the work as
professional commitment and voluntary activism. The professional staff, most of them
interviewed not presently working with the CHC, expressed more dissatisfaction to
’■oluntarism that misguidedly reduced the professional commitment to work and
ideological orientation that prevented balanced appreciation of evidence. On the other
hand, one former professional staff and one present staff lamented about increasing
orientation of the CHC to research, projects and professionals at the detriment of
voluntarism and activism. These two diametrically different perceptions flow from the
dilemma of transiting the CHC to be an institution in last five years.
My comments: The voluntarism in terms of organisational activities is evidently
very high - and acknowledged by all, irrespective of the views expressed above. This
is because of its foundational principle of being catalyst. As a consequence, last two
decades of the organisational work show tremendous awareness of responding to
disasters - both natural and social, responding to smaller and rural organisations whether working as organised groups or as informal voluntary groups on a wide
variety of issues - health as well as non-health, professional support to various social
groups and movements, participation in democratic rights and human rights
movement .nd grnnps, etc. e.e. Such netlvi.ies „e„ evidently taken up irrespective
nl having speeine projects on such subjects and at the risk of over-burdening the
staff with multiple activities. Thus, irrespective of how individual members of the
organisation perceive voluntarism, one gets strong impression that organisation as
such ,s not driven only by the funded projects but by certain commitment to
voluntarism.
Participatory:
Similarly, the appreciation of the term participation was different among the SOCHARA
members from the staff, and within staff there were perceptible difference between the
administrative and non-administrative staff. Before I go into details of responses it must
be said again that discovery of differences is not new; it has been there in most’ NGOs.
There is bound to be variation in the understanding of the initiators of the NGOs and
those who join later on, the variation is also related to one’s ideology, with the position
one has in the organisation and the aspiration. What is important is the consciousness that
such participatory method is considered good and desirable, and such consciousness was
very strong among all interviewed.
The members of the SOCHARA either looked at the participatory functioning as the most
suitable way or they assumed that that is how, broadly, the CHC is functioning. Within
the CHC, the participation is looked at as ethos and process; and not as systematic
component of organisational structure. At the heart of participatory processes and
structures is the willingness to promote participation, so in a way it is difficult to judge
whether one should rely more on processes or structures. However, a combination of the
two is an ideal situation but difficult to sustain.
In the CHC I discovered that all people I met testified to the participatory functioning of
the organisation. The responses ranged from defining participation as consultation by the
seniors with juniors to participation in decision-making. The former was stated by all
while the latter was mentioned by only a few persons. The critical elements in my
discussion with the staff on issue of participatory functioning were high level of
appreciation for discussing issues with as broad a layer of individuals as possible, so
*nuch so that there were criticism of being too consultative and thus wasting time in
meetings on one hand, and on the other hand some, disquiet on the way decisions were
made, the criteria used for decisions taken, opinion of the person not finding echo in the
decisions, etc. However, there was general appreciation of the fact that some space exists
in the organisation to question decisions or have a discussion on the subject Some
individuals in discussion mentioned their unhappiness about certain decisions but at the
same time were very clear in their appreciation of openness and humility that exists in the
decision- making bodies.
My comments: Over.ll, I found very strong commitment - both In ideology .s well
as practice, to the principle of participation. This internal principle is very
important because it helps in making the external health programmes related work
more participatory, and the acceptance by the new staff the political philosophy of
participation and democracy becomes easy. Since this is one of the most cherished
and practiced principle of the organisation, it needs to nurture it with all care In
the future development of organisation, it should keep in mind and eonseiously
prepare to tackle three problems that often impact the internal participatory
methods of organisation. One is the problem of time as It takes longer time in doing
work, and so issue of work efficiency will keep cropping „p. And here one needs to
create structures that encourage participation but at the same time facilitates timely
decision-making. Another problem is of the quality
an issne ofle„
J
professional staff as participation by wider group could mean Incorporation of
many news. In certain types of works, the democratic decision does not mean
a herence to high quality. Thus, one needs to work hard on separating out technical
work from organisational policy making - in the former the issue of democracy is
tot high while m th. latter it is. In each, different type of competency is needed, and
one needs to work on developing them. And third problem is the reluctance of
professional and senior staff to provide democratic participatory space
others.
“ Tn
bdi'!''e tl"' hiSh le‘l,"i“l
automatically
g^ves them high competence in deciding organisational policy matters and hence
matt
, n
d“i!i°nS “"S ‘"‘eS"0,",l
matter treated on par with the opinion of other staff.
,>pi"i<’" »"
Political philosophy:
ere are two essential elements among others that characterise SOCHARA/CHC’s
polittca phtlosophy, viz. community orientation and social paradigm of health. Both
hese c ements are very broad, their meaning need to be upgraded based on the
accumulation of empirical data and their practical appiiealion tested in specific contexts
Going through the work of last two decades, 1 gel an impression that the CHC has
operationalised its philosophy in three major ways:
inPUtS t0
und^T^^
NG°S and individuals for voluntary action, for
deepen thdr c
C°mmunity level and b>' motivating them to
role r
v COmmitinent t0 community work. The CHC functions related to catalyst
, networking, grassroots (community-based NGOs and others) training etc, fall in this
a egory. However, lt must be noted that the CHC has not opted for its own long-term
area specific community work.
g
well as educational campaigns and training.
eare „e„ in.e^ed
the
the C^ha T
Pan”=,P”" ” P°“Cy mak*nS aed advocacy. 1„ last few years,
the CHC has made trans,fon from generality of critiquing health system to touching
bas,c contours of the system and design its research and advocacy plans around them.
Generally, there seems to be a dynamic development of political philosophy - from a
voluntartst cnt.que and civil society efforts; to training and consciousness-raisingto a more system research and change approach. If one takes this dynamism as a
break from the pas, than one is likely to conclude that CHC has radically changed
1 ,ha>°h7cHc‘f
I°’kS ” “ *’ ’
than it can ais. be
1 that
CHC ,s making efforts to strike balance between the three. It is not
P ssible to pass definite )udgment on the situation as of now, the dynamic of further
development in coming time would make clear the real trajectory
cannot be smtplistieally explained. The terms such as d.-professionalisation needs to
be exammed more closely and weighed against the strategy of regulated and
ethtcal y committed profession. Similarly, demystification need, to be related to
X
!ThusPTr,?f' i"f<'n""“’n ’”‘l P’,ie"'S rigl“S W"hi“ ““
y.«m. Thus, while the basic political philosophy of the SOCHARA/CHC is not
outdated, the need for its dynamic interpretation and application i„ changing
simations must be appreciated and should be looked at as a positive part „f
As against this interpretation of mine, there are few strong critical remarks on the
political philosophy needing mention and discussion. These remarks can be grouped in
two categories. The first category remarks show extreme alarm on the CHC fast
discarding its “community orientation” “training role”, “grass-roots activism” etc in
favour of the “health policy” orientation. The second category of remarks are from
other extreme, show dissatisfaction over the CHC’s refusal to shed its “ideology” in
favour of “evidence-based public health”, refusal to change the language and priority of
work, and criticise the CHC for having half-baked, hesitant (vacillating) approach to
professionalising its work. Interestingly, the SOCHARA members are divided on this
issue - a few making remarks in each category, but the former staff members from
professional category (except one) and some trainees all made comments belonging to the
second category.
My comments: Indeed, the political philosophy will be more under scrutiny in coming
time. It therefore makes necessary that the integrative character of development is
emphasised. More so because in any organisation where the “action-based
community work” and “intellectual/academic research” work co-exist; there are
often practical organisational problems in balancing them. These problems often get
expressed as differences for the simple reason that the “action” staff are often
reluctant to read research findings and take care to qualify their statements or tone
down their rhetoric. The “research” staff on the other hand are too reluctant hastily
generalise, are cautious in their criticism and value “objectivity” more than taking
political position. The action-staff would demand “evidence” for their political
positions from research; while research staff would find it difficult to do “research”
where conclusions are already derived, positions taken and campaign initiated. On
the other hand, this uneasiness in orientation to work is also found in the differing
needs for administrative support. The research normally needs more skilled or
semi-skilled persons as support staff while the action projects would be having more
unskilled or street-smart persons in the administration. In research projects the
administration is normally trim and the need for administrative support is episodic
depending on the work phase of the project; while in the action-based work the
administrative staff is more populated and support need is constant and even rapid
response needed as crisis and emergencies are many.
In short, translating political philosophy into the work of the institution takes place by
different routes in research and action; and both have implications for the kind of
administrative structure one would need. The most important issues in the political
philosophy for the organisational work are: (a) how to ensure that political positions are
not treated as dogmas and final truths; but as dynamic process needing constant
reinforcement by generating the evidence and hence providing the strong foundation for
respect for research in the institution; and (b) how to ensure that the “action” is not seen
as an end in itself but also a learning process, and thus, regarding action as integral part
of the broader agenda of research for generating evidence for the political philosophy.
Others issues related to value system:
Talking to some of the senior members of the SOCHARA I was deeply impressed by
their concerns such as commitment to such mundane things as simplicity and cleanliness,
readiness to do any work, the concept of living wages - looking after the needs rather
than greed, strong concern for reducing gulf between the intellectual/specialised and
manual/unskilled works, not allowing the ratio of remuneration to the lowest and the
highest category of staff to exceed 4, non-hierarchical relationship and functioning. All of
them, I am told, are parts of the foundational values of the organisation, and efforts have
been made to operationalised them over all these years.
Evidently, operationalisation of such values was not found to be so easy. In last 20 years
they were experimented, discarded or modified. For instance, the idea of reducing the
gulf between intellectual and manual work is not attainable in any organisation unless we
are able to create condition where basic minimum education and skill of all staff is same
nnd very high. Such situation may provide an objective basis for not having division of
labour in the traditional way (manual vs intellectual). Overcoming such division of labour
through voluntarism in an organisation is not only unsustainable, it could also make
organisation authoritarian by forcing those who are not convinced about it. Thus, certain
values may look attractive in terms of personal morality, it is difficult to make them
ethical code of the organisation without creating pre-condition for making them practical
and sustainable.
While I think that value such as promoting equity by ensuring appropriate ratio of
basic pay between the lowest and the highest salary is both appropriate and to
certain extent sustainable, we need to review it regularly to ensure that organisation
does not lose good professional due to that policy. The staff and ex-staff members of
the CHC are divided on this issue. The professional staff is critical of this policy as
they find that it is a hindrance to paying higher salary to them, the staff at the lower
level find it a good policy as they get salary at the level higher than available
elsewhere. This criticism of the operationalisation of value CHC considers important is
going to only increase.
The sustainability of this value is directly proportionate to three critical factors: (a)
Having senior professional staff with commitment to working at low salary or they have
other family sources not requiring good salary, (b) The CHC is looked at and used only
as the administrative support base of for the otherwise full-time employed professionals
in the SOCHARA and thus the CHC not having any paid full-time professional staff, (c)
By technologically upgrading the work system so that the low paid non-professional staff
is not required.
All three options are difficult ones. In the (a), almost all NGOs have found difficult to get
professionals not needing “decent” salary. Adhering to this factor has either made the
founders as the only professionals in the organisation or they have attracted only the
spouse of well-paid professionals or businessman looking out for semi-voluntary
employment or they have attracted retired professionals. This inevitably pushes out the
professionals hailing from lower strata. Such individuals would be there to use the
organisation as stepping stone for higher jobs. The strategy (b) would change the CHC
from functional centre of the SOCHARA to its administrative centre. And (c) would
make the CHC without peons/office assistants and secretaries, thus demanding
technological up-gradation - a debatable value in itself in the SOCHARA.
I found the issue of technology, location and space as value related considerations as part
of value debate in the SOCHARA/CHC as somewhat misplaced and extreme. I believe
that practical considerations rather than moral should be applied on these issues. The
politics of technology or ideological underpinnings of technology and technological
change should be separated from the appropriate practical use of technologies and
space.
vastly, the issue of life style of individual members is problematic. There are over 30
members of SOCHARA, and'then we have staff members of the CHC. There is no way to
find a uniform consideration in the way each member lives his or her life. There are also
variations in the extent of social and family support each one enjoys, as that could be
important consideration for taking risk in life. And at another level, it is difficult to
determine the appropriate standard or level of life style that could be adequate for the
value system of the organisation or for the simple middle class living in
present-day
urban jungle of India.
Summing up:
Issues related to philosophy are not easy to resolve. More so if the philosophical
considerations and values; are eclectically put together. Somehow I kept getting a feeling
that the list of values to be followed is too long, too eclectic, not having a coherent
structure or being part of one theoretical position. This was less problematic when the
organisation was small, was trying not to become an institution, did not require more
professional staff for undertaking projects, etc. For at the time, the value system was
judged more in terms of its founder’s or Ravi/Thelma’s value system rather than value
system of all members and staff. With the SOCHARA growing into big organisation
(over 30 members) and expansion of staff and work of CHC, the longer list of values and
philosophical considerations is going to keep creating problems. By narrowing down
the focus and ambition of the CHC it may be possible to provide better coherence to
value system and bring down number of values to be universalised within the
organisation.
Lastly, it must be kept in mind that all values cannot be and should not be legislated
as rules within the organisation. Just as some people call laws as minimum ethics,
the rules of the organisation should also be looked at as minimum value or only
those values necessary to be universalised for the socially useful and efficient
functioning of the organisation. The rest should be left to the commitment and
goodness of individuals.
them opportunities to prove their point of view
to people
provides some ethical values
Its contribution to the other NGOs
If I could achieve something to promote community health (in my organisation),
it was mainly due to the contributioin from CHC and all those connected with it.
The very concept of community health was emerged with the support of CHC.
CHC was almost like a ready recknor for the latest on medical or community
health information
Showed me the value of low cost teaching aids,
especially the posters and songs
CHC means “friends” who are always
willing to help during a training programme and to share their knowledge. ... a
good sounding board to test new ideas.
Motivating and inspiring individuals
-
At the beginning CHC was a mentor. I was feeling lost in a new field and CHC
was able to show that values could be applied “even” in this (my) “speciality”.
.... During my post-graduate CHC was a senior friend and a colleague. One
could rely on CHC even when medical colleges and community health
departments were getting institutionalised. ... CHC is like a reference point - its
attachment to ideals is consistent.
CHC has been an inspiration, calling me back to my own commitment to people
especially those whoa re on T
“ ‘
the fringes
of society. It has provided a sounding
board for my own doubts, questions, and search for ways to> move forward in
my path. It also been a partner in the wider effort to bring in values of
cooperation, justice and peace in our country / world.
CHC has meant to me a refuge “a place to recharge” a place to visit when
spirits are down (but not out); to understand that “we are not alone” - that
there are others who also are constantly questioning, “trying to understand”
fighting for rights for the “voiceless” adding agendas if need be - but never
“shying from the truth”. It has also helped me to “have faith in fellow human
beings”.
CHC members provided me valuable mentorship and counselling. They helped
shape my understanding of community health and develop a broad, holistic,
interdisciplinary perspective on health and medicine.
The core team of CHC and many friends at CHC have been a ‘landmine’ of
shift in my paradigm of thinking, viewing, believing and acting.
personally, CHC gave immense opportunity and help to understand the concept
of Community Health.
CHC has been a source of inspiration to keep my passion for helping people
help themselves alive.
I also had an opportunity to go through one independent review of the work of CHC in
the Women’s health training programme (see Jandhyala Kameshwari, “An assessment of
programme in Karnataka, 23rd-28th February, 2001). The CHC acted a lead or nodal NGO
in Karnataka. The report states that, “Generally the partnership between a nodal
agency and other NGOs has been seen in a positive light. All the partners felt that
they have been allowed to retain their individual flavour in the implementation of
the programme. By and large the management and coordination of the programme
nas been smooth....... ”
Although there is no need to discuss the contribution made by the CHC in the
Health Task Force of Karnataka and in the drafting of its report as the same are
well-known, it must be noted that this intervention in the policy making at the state
level was a tremendous success in bringing about the impact of its work in last five
years. This task was carried out with lots of commitment and effort, and the
individuals I interviewed were highly impressed by the performance of the CHC in
this field. Another work of the CHC mentioned by respondent was on influencing
fhe medical education at the health sciences university of the state.
It must be noted that the study of the impact of work or programmes require more
rigorous efforts. One needs to go into each programme and not only look at how well
they were conducted by the CHC, but also examine its objective impact in improving
health or meeting other objectives and also how the recipients or beneficiaries
appreciated them. Such detailed examination of the programmes was not possible in this
review.
(E) QUALITY OF WORK UNDERTAKEN
I did not have time during the review process to objectively assess the quality of work in
the randomly selected programmes or projects. Indeed such assessment would be a task
in itself. Hence, this review does not have much - indeed almost nothing - in assessing
the quality of work undertaken by the CHC.
I indeed ask this question to many individuals I interviewed, particularly those who are
not directly involved in working at the CHC. The quality of these responses also did not
convince me to come to any reasonable conclusion about the quality. The responses were
varied but quite instructive:
The leading individuals are intellectually very good and whenever they have taken
up research-based work, the outcome has been excellent. There was high
appreciation of quality of such research-based writings. Some individuals expressed
disappointment that they have not done enough research, systematically published
their work in peer-reviewed, indexed journals nationally and internationally and thus
not done enough to influence the professional public health community.
A few individuals from NGOs where the CHC had organised trainings in the past
were interviewed and their general comment was very positive about the quality of
training. They showed more concern about the quality of follow up, as they
complained that CHC is taking so much work that it does not have sufficient time to
follow up.
Two types of critical comments were received on the quality of work in the
networks and the work at the community level. The first was that somehow
there was more orientation to number of events rather than what each event
was achieving. Thus it needed more rigorous, high quality and clearly defined
intervention in the network related work. One person said that good networks
cannot be built by “flying in and flying out”. The second was that the CHC
must strike direct roots in some community, build some good work and
experience in working at the community level and do some demonstration of
translating their ideals into reality at micro-level. According to this view, such
approach would take the quality of their training one step ahead.
One person made comment that while lots of documentation of work was
carried out, but it is very excessive and not systematic. As a consequence, one
does not find systematically designed and regularly updated training manuals
on some very important subjects coming out of the CHC. He lamented that an
organisation with training at the high priority agenda should have gained good
name by now in providing such training manuals. However, he was quick to
add that that did not mean that trainings provided by the CHC were not of
high standard but that it should have done something more systematic to
ensure that such training courses were documented in manuals, thus providing
much better guidance to trainers.
(F) FINANCIAL POSITION AND SUSTAINABILITY
As explained in the section on <organisation,
‘
the financial position of the CHC has
considerably improved in last few years. It doubled its i
-------------- income in last three years and its
annual tum-our is about half a rcrore
---- rupees. A concern was raised that much of the
income was from grants, and many such grants hadI come for specific projects, and that it
does not have enough money in its corpus funds and
reserves. So there was also a
concern for its sustainability - with an assumption that if there i
------ is more annual budget, the
sustainability is more difficult.
did not have detailed discussion on this with many individuals - not at all with anybody
on the financial statement of accounts of the SOCHARA, but with few individuals on the
issue of sustainability. So most of the points given below are my own comments.
(a) The excessive concern for the corpus funds should not be there as there are
organisations with less corpus funds and higher annual turnover than the SOCHARA’s
have been able to sustain themselves. Besides, with the low-interest rate regime in force
and with almost no chance of high interest rate times coming back, the income from the
interest of the corpus would be so low that one would need very big amount in the corpus
to earn adequate interest.
(b) Unlike in the past, there is relatively more emphasis on the monitoring and evaluation
by the funders and there is also more demand for focused work. The positive side of such
uemands is that they force the NGO not to keep doing anything and everything that
comes in its way, but do better planning and have long term focused work. If such
situation is alright for the CHC, its capacity to attract fund is still very good.
(c) Several respondents made a strong plea that CHC should explore possibility of raising
funds from the public and private sector corporate houses and their philanthropic
organisations. In principle it should be possible to raise such funds if there is no
unacceptable strings attached to them. Particularly efforts need to be made for increasing
corpus funds or for getting endowments that could sustain some of its activities.
(d) Induction of competent professionals in the team would help in the fund raising too.
Firstly their presence would make the organisation more attractive for providing project-
based work, and secondly these professionals in a course of time would be able to attract
funds for their own work.
(e) One viewpoint was that the CHC did not have to struggle too much so far for funds as
it had funders who were very committed to it and its requirement of funds was modest. It
also did not create non-moveable assets and thus remain somewhat tentative. This has,
according to this view, made the CHC somewhat less dynamic (lethargic) in fund raising.
It would be more dynamic in that field if it creates stakes in terms of non-moveable
properties (its own office building, for instance); and also has responsibility of supporting
a larger team of professionals. In fact, some amount of insecurity related to funds was
considered better situation than having it easily as that often robs away the organisation’s
dynamism.
zf) Since the turn over of funds of the SOCHARA has considerably increased, there is a
need to develop some expertise in the management of finances. Gradually both in-house
and consultant-based expertise in finance management would be needed for efficient
utilisation and creation of reserve Funds created for various core activities by
accumulating surplus money in specific Funds.
In essence, organisational expansion - in terms of human power and work/activities bring about more responsibility at the level of finances. In the present context of dearth of
good NGOs, it is not impossible to sustain work of good NGO provided one plans well
for fund raising, focuses work in the key priority areas, professionalise its working and
give sufficient attention to the outputs and impacts.
DISCUSSION ON SOME CRUCIAL ISSUES OF PRIORITY IMPORTANCE
(1) CHANGING VALUE SYSTEM:
Two milestones - the registration of independent society in 1991 and the change in
direction in 1998 - are impacting in many ways the foundational philosophy and the
value system, and that is making some of the society members concerned. They are more
concerned because further consolidation of the course could lead to major change in the
foundational philosophy and the value system. This issue needs very explicit discussion
within the organisation. It is not sufficient to argue that the developments since 1991
have not seriously impacted the philosophy and the value system. The following points
need to be clear in the minds of the members - particularly those who are associated with
the organisation since its inception.
The period 1984-90 is cherished as “golden-age” because it was formative, idealistic and
the most dynamic phase. The 1991 change was supposed to formalise and integrate those
values and ethos in a formal and independent organisation. However, it seems that the
society gave less attention to, or needs to appreciate, the objective impact that the
formalised organisation brings on the value system and ethos.
First of all, the formalised legal system creates both stakes and responsibilities. Not just
individual’s likes and dislikes, but the presence of organisation needs to be taken into
consideration more and more.
Second, there is pressure to expand the public space in the organisation and demarcate it
from the founding individuals’ private space.
Third, it. inaugurates the institutionalisation of the organisation. I think this is hardest to
accept, because if the founding philosophy and values are strongly against the
■institutionalisation”, or attaches premium on “de-institutionalising ” just in the same way
as one attaches philosophical and political importance to “de-professionalisation”, “de
mystification”, “de-bureaucratisation” and so on, the organisation goes through a phase
of denial (“we are an organisation but not institution”, and a phase of accommodation
(“we have institutionalised a bit but there is absolutely no change in our original
philosophy and value system”)..
Fourth, it makes it urgent to rationally understand the relationship between the “society”
(SOCHARA) and its “functional unit” (CHC). I feel that this relationship is not as
seriously discussed as necessary. Often the society is seen as the upholder of the
philosophy and the value system. The functional unit, as its name suggests, is the one that
operationalises the practical decisions and carries the burden of living that philosophy
and the value system. This does not mean that some of the society members do not get
involved in providing lead and direction, but that the essential burden of
operationalisation is collectively on the functional unit and not on the society.
Fifth, the establishment of the formalised unit brings into the relationship another force,
the paid as well as honorary staff of the organisation. It is this group of people and the
way they work that remains at the centre of discussion on success and failure of
implementing ideals. Despite all idealism, one needs to accept that once we have
employees, we become employers. For activists entering into the running of paid full
time organisation, it is very difficult to accept the reality of the employer-employee
relationship. Over and above that, it also brings about hierarchy. The most important
challenge for a sensitive voluntary organisation is not to strive for the utopian state of the
elimination of the hierarchy, but for how to have hierarchies without hierarchical
relationships.
I think it is necessary to look at this dynamic of development in order to understand the
stress that the original or founding philosophy and value system keep experiencing. The
semantic of terms may not be useful because each one may define “institution”,
bureaucracy”, “hierarchy”, etc. differently. What is essential is the acceptance of the fact
that in the formalised paid organisational structure, they are present; the only thing that
we can do is to make efforts to give them different form, a more humanistic form. In the
relationship between the society and the functional unit, we need to pay attention to two
processes: (a) the functional unit should never be allowed to become the utilitarian
appendage of the legal unit, the society, and (b) put in place the formal structure and
processes of autonomy and empowerment for the functional unit(s) and the individuals
working there. Attention to these two aspects is important simply because the society and
the functional unit exist in power relationship and the society being a legally empowered
body, always has more power than the functional unit. The issue of ethics in the structure
of relationship needs to be addressed here.
It is often argued that certain values are eternal and must be upheld under any
circumstance and organisational form. Here, we need to filter out the secular ethics from
the individual morality. The latter is important for each individual and it is bound to be
different for each depending upon the cultural, religious and other upbringings, but the
former is the one that deals with the standaid of conduct in the secular and public space
and hence needs to be continuously contextualised. Moreover, we need to discuss this
the idea of comparing the present with the past. Why do we assume that the idea
and philosophy we started with ware qualitatively superior/better than what we
have on the ground today? Perhaps it makes better sense to understand evolution of
the ideals simply because there is always continuity of certain elements and the
change in others. The elements showing continuity are also not eternal, and simply
because they survived do not make them eternally ideal. A reason for that could be
that they are kept alive artificially, but have lost the actual base within a majority of
the society members and the staff. Those who have not survived should also not be
seen as dispensable simply because we may think them important to make practicable.
The only suggestion that I can give is that the SOCHARA/CHC need to have very
hard and realistic look at the philosophy and value system of the organisation.
There is a possibility that it may become an endless discussion, but that should not
deter it to have appreciation of the philosophy as it is presently practiced and not
get carried away by the philosophy as it is idealised.
(b) ORGANISATIONAL STRUCTURE AND PROCESSES
One of my strongest feelings is about the structure of the organisation. I narrated some
aspects having bearing on the structure in the previous point; here they are developed
further. Several issues need discussion:
First, the process of organisational change seems to have started in the CHC but not
reflected in the SOCHARA. This is a very paradoxical situation simply because the
changes introduced since 1998 in the CHC came from the decision of the SOCHARA.
Perhaps the members have not fully appreciated or understood the meaning of the
changes. The change in the CHC is that since 1998 the process of institutionalisation and
professionalisation has been augmented. Correspondingly, there is little attention paid to
the changing role of SOCHARA. We need to face the question - if the CHC
institutionalises or reaches a higher level of institutionalisation and
professionalisation, what would be the role of SOCHARA?
Second, the first two (1984-1990 and 1991-1998) phases of the organisational
development, the SOCHARA was a support network nurturing few individuals who had
made commitment to work differently, be a sounding board and generator of the ideas. In
many ways, much of the organisational work as against the programme-based work were
centred, around SOCHARA and the CHC was just a functional unit. This system has
continued even now, and to my understanding, one of the strongest criticisms of some of
those who worked in the CHC in last five years implicitly is in relation to this system.
This does not mean that there is absolutely no participatory system. On the contrary, most
of them did describe it as participatory system. However, the problems I found were more
with the content and context of participation, because participation does not automatically
lead to democratic and empowering system. So we need to discuss the participation and
decision making in the areas that matter, the areas that have formal power sharing
arrangements, rather than looking at the participation in formal sense and often in the
softer areas.
Three, the executive/managing committee of SOCHARA is by law and in effect should
function as the Board of Trust or Governing Board of the CHC and not as the executive
body. In a way a perusal of the minutes of the executive committee shows that it is in fact
moving in that direction but without discarding its executive functions and creating
legitimate and formal body of the staff to devolve those functions. It is absolutely
essential that the staff, by having circumscribed and devolved formal executive functions
learn to govern the organisation and learn to evolve its own development plan. Presently
ouch processes are there but at the informal plane, and that is making many individuals
tentative in committing themselves to the processes.
Four, this would necessitate the demarcation of role/functions, powers and system of
accountability between the staff body, the coordinator, the executive committee as
governing body and the general body meeting. Given these structures, one would also
need the meeting places - where they are able to jointly meet, consult each other and iron
out differences from time to time. I believe that the EC and the GBM should act as policy
making bodies, peer reviewers, sounding boards and refrain from directly exercising
executive function unless absolutely essential or when there is a course correction found
to be necessary.
Five, the SOCHARA needs to tighten its norms for membership and reconsider its earlier
decision to increase numbers. It must be kept in mind that CHC is no longer a small
organisation - its financial turn over has increased several times as compared to early and
mid 1990s - and there are stakes involved. The current practice of accommodating
individuals in the SOCHARA if they cannot continue to be a part of the CHC must stop.
It must also overhaul its membership by keeping in mind those who are genuinely
active - not in general as a part of network or ideology-sharing but specifically for
the CHC/SOCHARA - and those who share the vision for the future of the
organisation.
Six, the CHC needs to be given a more systematic and formal shape. The CHC cannot
be governed only using the rules and regulation of the society, but it also needs a
separate administrative rules and structures. I am sure that there are administrative
mles, salary scales and other things existing as a part of the administrative orders adopted
by the EC from time to time. But this is not sufficient - they need to be brought together,
openly debated, modified and in consultation with the staff adopted jointly by the EC and
staff.
(c) INSTITUTIONALISATION:
The most intriguing aspect of the CHC/SOCHARA for over years for me has been its
concept of being facilitator and catalyst organisation and not being an institution. I have
made lots of efforts to understand this concept as applied to organisation, but not sill
understood fully. So if my comments betray my ignorance, I beg apology in advance.
I received a very consistent (very few people doubting this aspect) response from all
over the country from those who associated with the CHC for short duration as a
part of network or visitor to the CHC, and then kept in touch and remained in
active contact. All of them told me about how they felt inspired, how they could get
some vision and how such association impacted their decision about involving
themselves in community health. However, some more discussion brought out several
issues that are worth pondering about. First, there is a mixing up of the individual’s
personality and the organisation. Some of these individuals were very appreciative of
individuals but not so much of the organisation. Particularly Ravi Narayan was identified
as highly suitable person as mentor, facilitator and the one who could provoke them, but
not the organisation as such. I know that individuals give shape to organisation and so
they cannot be completely separated. But if the unevenness of the development between
the individual and the organisation keeps widening, the ups and downs, the changing
priorities etc of the individual can have sharp impact on the organisation. Secondly, it is
very evident that with the gradual withdrawal of Ravi Narayan, there is corresponding
change in the way the organisation is playing the role of the facilitation and being
catalyst. This is based on my conviction that any organisation, having basic dynamism
and social commitment, at some level acts as catalyst and facilitator. Thirdly, the
organisational role as facilitator often depends upon how professionally well it functions
in providing training, undertaking research and in advocacy. Its work on health policy
and research, have those components, but they are still under-developed. One of the
reasons for the under-development is that it is not able to find suitable and modified
organisational role as catalyst and facilitator; and stop looking back as more
personalised approach that was there in the informal phase of the development of
organisation.
Fourth important issue to ponder over is the kind of needs and demands that are now
emanating from the NGOs/CBOs and public health bodies (including professional bodies
and medical colleges/umversity). In the 1980s and early 1990s the CHC was acting as
a catalyst and facilitator in a different social and political environment than is doing
now. From health as being community health activity - the paradigm shift that is
well documented by the CHC - it has acquired some additional meaning, one of
them is the also being a right and political process. The health as a right’s issue was
not as prominent earlier as it is now. Besides, the NGOs are undergoing rapid
changes. The impact of economic reforms on the NGOs is enormous. I have a feeling
that the list of what is to be catalysed and facilitated has expanded considerably and
within that the socially relevant research, the policy advocacy, monitoring
implementation of policies and impacting mainstream have emerged as newer areas
having direct connection to the developmental process.
WAY FORWARD
What is the best way forward for the CHC? Answer to this became more difficult as I
progressed in the review than I had anticipated at the time of starting the work. I am
giving here a very brief and tentative view, but it can be modified and elaborated in the
-ourse of discussion with the SOCHARA/CHC in coming time. Besides, issues and ideas
expressed in the previous section — some in very provocative way — provide lots of
material for discussion and decision-making.
Three alternatives kept coming back in discussion: (a) Make a retreat, go back to pre1998-9 situation and continue doing what the CHC did between 1984 and 1998. The
recent changes are institutionalising the organisations, divorcing it from the community
work, making it more research oriented, expanding its strength and making it financially
non-sustainable, and so on. (b) Build on the great achievement of last 20 years, identify
its strengths and build it as institution in a planned but bold way, preserving some of the
values and ethos, and charting a course towards establishment of a good community
health institution, (c) The CHC should be closed down. This position was not explicitly
taken by anybody, but some individuals indirectly mentioned such possibility. The
factors that prompted such response were: (1) institutionalisation would be a worst option
than the closure, (2) unable to carry on because the core team is tired, burnt out or has
changed its direction.
I do not think that the third option should be entertained at all. It would be the biggest
disappointment if decision to close down an organisation after it has done tremendous
work in last quarter century. I also do not believe that there is a dearth of new generation
of committed professionals to carry on with the work of the organisation. Hence, the
choice is between the option (a) and (b).
Here too, I feel that while it may be useful analytically to dichotomise between being
organisation but not institution and the strength of being catalyst as compared to
weakness in becoming institution; I do not see such dichotomised relationship between
organisation and institution; and in being catalyst and institution. For me all
organisations are different kinds of institutions, and all good institutions must
provide inspiration to those who work there and others so they are also catalyst in
certain ways. Institution building does not mean that the organisation should
become too big or should stop having ideals and should stop inspiring.
Concretely, institution building is a process that (a) changes mind set of group
governing it from seeing the organisation as temporary to permanent entity; (b)
makes the organisation more stable and giving look of permanency, (c) increases the
role of organisational system so that it does not rely too heavily on one or few
individuals for its survival, for good functioning or for its value orientation; and
lastly (d) provides continuity by creating its own image that helps in attracting and
retaining right kind of individuals for perpetuating its work.
This process need not take place in one place, in one building with over-centralised
bureaucracy or the organisation having only one priority. The process may take
place in several decentralised centres with one governing entity coordinating and
providing guidance to such process.
Recommendations:
During my interaction with ■various people from SOCHARA and the CHC, I did find
some strong differences in perceptions
i
, > — at -philosophical/political
level and in actual
work - and they are to some extent reflected in the report and also discussed. Some views
may appear very extreme, yet I think there is
’ and the scope within the
is imaturity
organisation to make adjustment and continue with- the process started in 1998 for
building institution.
I am not going into details of changes to be made in
administration, process of
organisational functioning etc as recommendations on them
are already in the text of the
report. I will write only on few points related to the institution or organisation building.
(1) While lot is said about bringing back the spirit of first decade of CHC (1984-1993/4)
it seems to be more nostalgia and “manner” of making points. The real tension appears
to be on how to strike balance between the faction” work in the community and the
intellectual” work of research and the “campaign” work of advocacy. This balance
-s not easy; as it seems that various actors involved in this process have strong views,
one of them being that orientation towards research is shifting focus or priority
from and perhaps detrimental to the action or community-based work. These views
need to be reconciled, and the appropriate place for all three components must be
found under the larger framework of the SOCHARA.
(B) ORGANISATIONAL STRUCTURE
The factor of structure is very important in keeping organisation alive
to newer
challenges, impersonalise it by making it a public space and by ensuring a system of
participation. My first impression of the structure was that it was very weak and
traditional. Later, my detailed examination of it only provided part confirmation of my
eehng. It is not surprising that unconventional thinking and work by NGOs in our
country are often carried out in an organisational structure that is very conventional. But
this produces imbalance and keep creating its own crisis. So one needs to pay more
attention to the structure and be innovative in evolving something more appropriate to the
work for which the organisation is created.
Another important fact is the organisational processes, and there is dynamic relationship
between the structure and processes. Those who do not see structure and processes as
inter-dependent, normally pay more attention to processes rather than structures. Besides,
structures would be virtually empty and useless if there are not good processes to make
them workable. The problem with the emphasis on the processes without structures is that
they could appear and get perceived more as top-down, benevolent and paternalistic. The
structures with good processes help in making the power-relationship explicit and good
structures could help in distributing power in such a way that it allows more initiative and
development of new leadership or political voice.
lhe organisational structure of the SOCHARA/CHC is very simple and based on the
legal requirement of the society. In that sense the organisational decision making
structure is basically that of society rather than CHC. The general body of SOCHARA
elects the executive committee and the secretary to the executive committee also works
as coordinator/director of the CHC, the functional unit of the SOCHARA. Since within
the CHC the structure is only around the job designation or position accorded to each
staff member, the participatory functioning and participatory decision-making are left to
the processes sustained through coordinator’s initiative.
General Body:
All members of the SOCHARA constitute the General Body. It has 34 members. For last
few years the SOCHARA has been making lots of efforts to expand its number by
motivating individuals to join the society. The membership appears to be drawn from
three constituencies. The first one is its core-constituency made up of those who have
been associated with the society from its inception or for very long time. The second
constituency from where members are drawn are the peer and network groups, the long
time supporters and participants in the training and other programmes. The third section
is made up of the former CHC staff members, trainees, associates and others.
The annual general body meeting of the society, as compared to the number of members,
is not well attended. A quick look at last ten years of the annual general body meetings
show that the attendance was from 60% to 30% of the total membership. The core team
of 7 to 10 individuals has been consistent in attending the meetings and also in sharing
the responsibility as Executive Committee members. This consistent low attendance
-ould have been one reason why the SOCHARA tried to recruit more individuals in its
general body as members in last few years. However, the attendance has not improved.
The efforts to get more people involved and take responsibility in running the society are
laudable. In every organisation there is always time when one needs to think in terms of
getting fresh blood and new ideas. However, it needs to be kept in mind that such
initiatives must be well planned and membership offer should be based on mutual
compatibility as appreciation of the responsibility for being a member. Besides, in a
society having lots of people who are <otherwise very busy in their own profession and
activities, it will be impossible to find1 a time convenient to all for the meeting. So a
smaller body would provide more flexibility in arranoino
arranging meetings
convenience of all. Thus, it would be much better to look for replacement of
members who are retiring and not able to take more responsibility and the new
entrant’s membership must be accepted only on the promise of discharging some
mimmum responsibility. The individuals living far away from Bangalore should be
offered membership only on imaking arrangement for financing the participation of
the individuals for the meeting.
There is one more reason for exercising caution in expansion of membership. The
SOCHARA/CHC are not activist organisations, though some amount of activism they
undertake as a part of their activities. They are essentially institutions or establishments
with full-time jobs at stake, high budget raised through grants and stakes in terms of at
least moveable properties, instruments, books and so on. Add to that an impressive
history of twenty years of work. For such establishment it is necessary to ensure that its
chief governing body is trim, active and involved. There are also examples - several of
diem in Western parts of India - where the establishments run by societies have been
taken over by the members who made slow but deliberate entry.
Thus, those members not meeting minimum requirement of discharging
responsibilities should be allowed to drop out and the entry may be restricted to
only those who make commitment to provide minimum inputs in the society’s work.
Executive Committee:
The executive committee is the real day-to-day decision making body. It is exclusively
made up of the members of the SOCHARA elected on this body at the AGM and has
tenure of three years. With strength of seven members, it is natural that a big majority of
the core and regular members of the SOCHARA work as EC members.
First of all, the attendance at the EC meetings is fairly good showing that the core-regular
members of the SOCHARA are deeply interested in the work and welfare of the CHC
and all other activities of the society. Second, the frequency of the meetings is as per the
legal requirements. Minimum two meetings in a year do take place, in a few years the
maximum number of the EC meetings is much higher. Three, the minutes of the meetings
show that EC carries out a wide range of decision-making. It decides on all major policy
issues related to the work of the CHC and the SOCHARA, receives reports of work
carried out by the CHC and takes decision on it; and at the lower level takes or ratifies
decisions on simple administrative matters like sanction or approval of rejection of leave
application and other problems. Between two meetings, the secretary, who also works as
the coordinator of the CHC, is empowered to take decisions on the routine matters and
also take initiative, with the aid of staff and others, new activities; but the same are
reported at the EC, discussed and ratified. The staff confirmed that usually the secretary
consulted them on important matters and the office meetings were conducted before
.aking decision and so on. This indeed is a good practice, and works well in small
organisations. However, the informal consultation with all, however regular, start
bringing strains on the participatory methods in larger organisation for simple reasons
that there is greater unevenness in qualification, involvement/commitment and relevant
experience of the staff. Hence it is necessary to find a practical way out so that the
participatory processes are not stopped and yet, the day-to-day decision making body
assisting the secretary is compact, smaller and functioning regularly.
The EC as a decision making structure in the period between the General Body meetings
seems to have worked well for the SOCHARA. The general acceptance of it in the staff
of the CHC has something to do with the processes in which care is often taken to invite
staff members for discussion during the EC meetings. At the same time in my discussion
with a cross section of the staff and former staff members about it in last five years has
elicited some responses that need to be addressed to. The administrative staff has been
finding itself in some disarray of late because of the sense of insecurity generated by the
uncertain future of the organisation or due to discussion on the re-organisation.
Somehow, the message from the EC has not been clear enough to allay some of the
problems of theirs or they are not able to articulate their problems or they are finding
themselves not fully competent to the new tasks coming in the way. My collective
discussion with them could not generate enough material to pin point the problems except
a statement saying that they are not trusted enough, but their problems, if they are
significant, are worth looking at. In any case more needs to be done to tackle this issue of
trust as it has been articulated.
some of the former staff members have also raised issues related to the considerations
that go in making certain decisions. The former professional staff also aired some similar
issues. One area they showed lots of concern was that criteria used for judging their
competence and contribution. For instance, at least two former staff members said that
one of the reasons they left was related to non-appreciation of their competence to
represent organisation in meetings, particularly national and international meetings. They
also raised issue that such decisions normally favoured the SOCHARA members for
representing the organisation while they were actually working on the subject on which
such meetings took place.
My comments: The critical remarks on the decision making process throw some
light on the need to work out a structure that has formal representation of the CHC
staff and at least strengthening the inter-phase between the SOCHARA and the
staff. This issue will keep becoming critical as the CHC expands its activities (as it is
doing now) and more professional staff keeps joining.
The CHC Staff:
There are several structural and functional issues related to the staff raised by individuals
I interviewed. Most of these issues take into consideration only last five-years as they
seem to have come more forcefully with the expansion of the project based activities and
community health training.
a
Two issues discussed above are found (. be import..,. (1) Tl,e lss„M of
ormal processes of the consultation with the staff are weak, on the contrary they
are very much there and consultations and their democratic nature are
a knowledged by most, but that has not overcome the uneasy feeling about that
demons and the justification for decisions taken. It might help to formalise those
P cesses so that participation does not look selective. (2) Structurally it is
impor ant to demarcate the areas of direct involvement of SOCHARA members in
re'J0^
the CHC and the arCaS Where thC CHC-Staff has
autonomy to
present organisation (CHC and not the SOCHARA) and autonomy to design and
undertake activities. This demarcation should go hand-in-hand with the
s rengthening of the inter-phase between the SOCHARA and the CHC so that there
is a formal forum for interaction and resolution of problems cropping up.
Other issues raised in interviews are as follows:
(a) Some of the former senior, professional staff has found the designations used
problematrc. The designation as Fellow was found to be less useful while working with
the on side organisations and they felt that better designations are needed so that they
could help them in facilitating their work.
Y
My comments: This looks trivial i
---- ---- issue, but I think designations could always be changed
if there is a need or <'demand from the staff. However, care needs to be taken that the
designations reflect the NGO• or institutional character of the organisation and do not
sound like corporate entities.
(b) The issue of right mix between the project work and general work underpinned some
andelk
m " Whve n°bOdy °PP°Sed ‘he ““ ,ha' prOjeC' s,,ff sh™ld
a h' dT ° m W°r S' there ™S S<>me an’°“”t of diSh“i« on how that could be
ch,eved. Issues Itke the projects also flowing from the core concerns of the organisation
Ure mts should not be looked at administratively in terms of number of hours put in for
the „workrcommitted
,y
d'"m”8the°f “project
“ proposal,
“ W°rk how
P“' “and who,OpiC
Of ,1»
^ond
decides the work that is
'
project-based and general, etc were mentioned. This does demand not only some clarity
but also consensus among the staff.
My comments: I was not surprised to find that there was a discussion about the project
work and institutional work. It may not be possible to put such discussion at rest at all as
most of the NGOs survive on projects and they do not have any permanent source of
funds. But few measures might go a long way in reducing such discussion: (i) it is
necessary to make sure that “project” work is not distinguished from the
“institution” work. This could be done by ensuring or making it known that project
is taken simply because institution wants to do that work; (ii) by appointing all staff
as temporary institution staff and not as project staff, the work of project is only
assigned or responsibility given to the particular staff; and (iii) performance
evaluation is for the performance on all the tasks assigned.
(c) An indirect mention of the way projects are formulated and their connection to the
overall plan of organisation development was made both by some SOCHARA members,
peer-groups members and present and former staff. A muted concern whether the project
would be taken on the basis of availability of money from the funders or they would be
evolved as a part of the raising funds for the short and medium term activities planned
was also raised.
My comments: There is no evidence and I am not convinced by the arguments that
some projects were taken by the CHC just for getting funds. On the contrary, there
is evidence to show that there is a lengthy process of developing action plan for the
organisation, and thus some amount of planning in development of organisation. At
the same time, there is need for more rigour in planning of the programmatic areas
of the action plan. Perhaps writing of working or discussion papers for each
programme of the organisation may be useful. Such working or discussion paper
should do rigorous literature review to summarise the present state of knowledge on
that programme, describe work done by the CHC so far in that field, provide
rationale for the kind of work that CHC should be undertaking in the next five
years and make suggestions about how practically it could be accomplished by
converting into relevant project or projects and raising funds for them. This will
provide not only an additional, intellectually more organised input to current efforts
in the planning but would also satisfy the present critics on how and why project are
being taken by the CHC. This may or may not stop such criticism, but the
minimum it can do is to provide strong political and public health rationale for the
projects being pursued.
(d) Several people raised the issue of second-line leadership and lamented on the
structures not being conducive to development of such persons. A few were outright
looking for motives for “not allowing second-line of leadership to develop”, while all
others (big majority) were more understanding about the problems of developing and
retaining second-line of leadership in the NGOs but wanted more reforms to ensure that
such leadership develops at the earliest time. Interestingly both the groups generally were
of the opinion that such leadership would evolve only through better planning,
positioning of individuals in the organisation, provision of autonomy in work and more
tolerance to different ways of doing things. The former on the other hand articulated need
for more institutionalisation, representation in decision-making, professional approach to
work and better salary structure to retain emerging new leaders, the latter group was more
reticent in talking about such issues but wanted such second line to develop by paying
extra attention to the task within the existing structures.
My comments: This is both a difficult issue and also a delicate issue in discussion. The
NGOs in India a personality-based and not based on organisational system is an oftrepeated remark used both to describe as well as defame the NGOs. I am giving
comments on the assumption that there is genuine problem in finding new
leadership. Two problems often prevent the founding individual(s) from passing the
organisational leadership into new hands: (a) lack of such individuals, or the right
individuals not staying in the organisation for “long enough”, and (b) fear whether
in their absence the political commitment or idealism with which the NGO was
started would be sustained by the new leadership or leader. The first problem in the
context of the CHS has two dimensions. First, is there any individual or individuals
in the SOCHARA ready to leave their current work and make commitment for at
least five years to take leadership of the CHC? In my interaction with the
SOCHARA members, I did not get any hint to this effect and so I assume that there
is none. The second dimension is whether from the professional staff of the CHC it is
feasible to nurture such leaders. At the time this review was carried out the CHC
had lost most of the professional staff so it was difficult to say anything; but in
general if conscious policy is pursued, it should be feasible to prepare new people for
the leadership. Perhaps it may be useful to start experimenting by appointing one or
two potential persons as deputy or join coordinators of the organisation with a
proviso that after two or three years they would be replacing the coordinator. The
second problem of sustaining old idealism or changing the political direction of
organisation is directly connected to the SOCHARA’s capacity to provide political
leadership rather than founding member’s presence or absence. My suggestion
would be to strengthen the political capacity of SOCHARA rather than being
dependent on a few individuals for political correctness.
(e) The coordinator has decision-making powers between two EC meetings, and some of
the major decisions by the coordinator are reported to the EC, discussed and ratified.
Much of the criticism on the decision-making of the coordinator reported was related to
the style of functioning, and so comparison between the past and present coordinator,
were at that level. While I did suspect some motives in some of the responses particularly those that made comparisons, I chose not to confront but accept them at the
face value, as it is always very difficult to have individuals with the same style. At least
one former professional staff while airing criticism of style, on his own admitted to the
humility and transparency, thus dismissing the ideas of motives.
My comments: My inference is that much of such criticism came because of three
reasons: (1) the tension between direct organisational commitment and desire for
autonomy at the level of work, (2) inadequate appreciation of the deadlines for
completing tasks and accountability to the funders, and (3) strong disapproval of quick
administrative measures without allowing the process of negotiation on the problem at
hand. Structurally, one of the ways to reduce (they can never be fully stopped) such
problems related to style is to have a small formal committee of drawn from the staff to
assist the coordinator so that such tricky decisions have wider support within the staff and
at the same time the coordinator retains both the veto power as well as emergency power
to make decisions. My own feeling while going through responses on the organisational
structure is that the complexity of the evolving work and organisation demands more
formal involvement of the staff in the management of the organisation, more frequent
meetings of the EC or the EC to act like a governing board and devolves the day to day
executive powers to the coordinator with a staff committee to assist in the process. The
minutes of the regular meetings of the committee could provide better insight to the EC
about prioritising its intervention. This process could be a beginning of both more
thinking in the SOCHARA-CHC relationship on the managing the staff-based
organisation and promotion of the principles of participatory and self-management at the
level of CHC. This would provide a meeting ground between progressive staff policies
(rules and salaries) with the organisational management. It will also provide some
alignment between the demand of commitment and political consciousness among the
staff from the SOCHARA and problems of working as employees in an organisation
whose objective is to operationalise objectives and decisions of the SOCHARA.
Rules, Salary scales and financial position:
The rules and regulation governing the CHC are fairly elaborate and cover most of the
essential requirements. There is healthy respect for labour laws - making provision for
the social securities and staff welfare.
The salary scales are also better than the most
of the community-based NGOs. One
person from the NGO made a comment that they are high. A salary revision was carried
out about a couple of years back. However, as mentioned in the discussion in the
philosophy and values system section, there is f
definitely a tension between the
commitment to equity and the salary expectations of the
-J senior professionals, and that has
resulted into loss of some professionals. Another
tension mentioned by a former
professional is ;'
about the parity of salary practiced between the social science
professionals and medical/public health professionals,
—. Third tension, reported by two
individuals, is between the lowering of salary of :
seniors thus paying them less than
market value” while giving salary that is more than “market value
------------ e” to lower level staff
in order to meet the value of equity. The fourth tension, not mentioned by any respondent
but implicitly present (and found to be a tension in other NGOs) is between emolument
for those who involve themselves in community level work and those who do research
and higher levels of training. The last two issues, equity and the action-research, are the
most difficult to resolve and that is the reason why the action/community based NGOs
are not able to build good tradition of rigorous research by retaining good researchers
and the research NGOs are not able to provide place of pride to action oriented
community workers without violating principle of equity. There is no easy way out of the
dilemma.
Unless an NGO keeps getting adequate number of highly committed professionals
ready to work at relatively low salary (less than “market value” of their labour, or
less than UGC scales of associate and full professors), it has struggled to retain good
researchers. The supplementary ways in which relatively low salary is matched with
retaining them, are providing them more autonomy, rapid career development and
high profile, possibility of becoming coordinator of the organisation, allowing them
to undertake private consultancy outside office hours (on sharing basis with the
organisation or by allowing full benefits), and so on. That is making it possible for
them to have higher job satisfaction and other non-material benefit with possibility
of getting material benefit by working extra in private time. They need to be looked
at to understand the extent to which such strategies and other innovative strategies
thought of are compatible with the value system of the organisation.
The financial condition of the society is in very good health. I had an opportunity to study
the balance sheet of the organisation for the years 1999-2000 to 2002-3. The annual
income of the organisation more than doubled in this period and number of activities for
which funds are utilised has shown steady increase. I have not studied the books of
accounts but based on the auditor’s report and the details given in the balance sheets I
feel that management of funds is done in a fairly good manner. There is no doubt that the
CHC as an organisation has established a good financial base to take off in case it wants
to make a transition to a more complex institution.
Other issues of structure and policies
(1) One former senior staff member expressed very strong feelings on the organisational
and staff policies, particularly with regard to the professional staff. According to him,
organisationally the CHC had become: (a) a nursery centre for fresh medicine graduates
join explore the field of community health as a possible career, (b) a sabbatical centre for
highly qualified professionals when they are on sabbatical period from the parent
institutions for very short period of 6 months to 2 years, (c) Post disaster make-shift
shelter for professionals who quit their jobs or had to shift to Bangalore due to untoward
professional/personal distress, and they join CHC until they find alternative, and (d)
Professional vruddhashram centre, as a good retreat centre (retired men’s paradise)
rehabilitating 60+ yrs retired professionals. I was not able to separate out humour from
the serious point on my own, but soon I realised that this was a serious point as he went
on giving few examples in each category to buttress his argument. Essentially he was
arguing that there was too much reliance on stop-gap arrangements rather than building
core professional group within CHC; and was arguing for development of an institution
that provided opportunity to professionals both for doing something socially good as well
as develop their career within the CHC.
My comments: All four categories - nursery, sabbatical, makeshift support and
vruddhashram - are important ones for any institution. It must nurture new talent
and thus it needs to be a nursery. The provision of time for reflection to those who
are sabbatical would be a great input. Makeshift support to talented individuals is
not a bad humanitarian commitment. And lastly ensuring that a retired but
dynamic and idealist individual finds a place to continue work is also a laudable
objective. Hence, I have no problem if organisation is pursuing such policies.
owever, I also agree that they should not be pursued in lie of the work of building
professional core or core faculty of the institution. An institution having stable core
of professionals would be able to pursue these four categories of work with much
more confidence and as supplement to the work carried out by the core; than the
institution lacking such a core.
(2) In the appreciation of organisation, the personalities cannot be kept out because they
both shape the organisation and provide it with public profile. More so in the case of the
CHC as for outsiders, it has somehow got identified with Ravi and Thelma for very long
time - and this despite the fact that they had taken sabbatical for considerably long time
in 1990s. I has lots of difficulties during the interviews to separate out points made on the
CHC as organisation and on both or one of them. As far as possible, I did ask for
clarification but it was not possible always. When such clarification was sought, I had
fiaund that the issue pertained more to the individual than to the organisation or’it was
assumed that both were same. While this is not surprising, it makes simple issues more
delicate than they ought to be. On the other hand, some of the respondents very forthright
in making some strong comment on the place of Ravi and Thelma in the CHC. This was
also natural because an association of such a long time was bound to personalise the
place and the image of it. With that explanation, few strong points made are worth
mentioning so that in future planning of the organisation they are kept in mind. Six out of
all individuals interviewed (included three former staff members and three others) felt
rather strongly that the CHC was a family affair and others had only temporary place
there. There was also an indirect mention by a few others in terms of availability of
‘public” space within the CHC. At another level, several respondents positively
appreciated (three even saying that they idealise them) Ravi and Thelma but were highly
concerned about the future of the CHC if they burnt out, or decided to do something else.
Such individuals usually also felt that for the sake of future, the SOCHARA should take
the path of institutionalisation - as one respondent put it, “it is inhuman to keep expecting
them doing the kind of work they have done in last 20 years”. They felt that only
institutionalisation could motivate some professionals to stay with the CHC for longer
time and thus relieve Ravi and Thelma from all responsibility. Three of the six
respondents who saw CHC as family affair imputed different kind of motives for not
institutionalising; such as they were insecure, they could not work with equals, and so on.
My comments: I found the discussion on this topic difficult to handle. I know that
committed individuals in the process of building institutions blur the distinction between
personal space and office space, not because they want family to dominate office, but
because in order to ensure that the organisation survives and function, they even give
their family time to office and often make family to slog for the office. So on one hand
there is high level of personal sacrifice involved in the mixing of family and organisation.
On the other hand when survival crisis becomes a permanent one and the blurring of
space between family and office also become regular, the problem like the one narrated
from discussion become more visible and start becoming even deterrent to emergence of
new independent leadership. It is indeed not possible for me to pass any judgment on this
issue except to say that in order to get out of this situation, the CHC should be using
its current good financial and organisational position to develop new leadership thus
reducing pressure on Ravi and Thelma to continue providing additional personal
support to the organisation. In addition, the suggestions made while discussing issue of
developing new leadership may be used for overcoming this problem permanently.
(3) Although there is no evidence that the SOCHARA/CHC have connection to the
Church or Church-based organisations, or that its policies and work have anything to do
with religious activities, several persons, including a few members of the SOCHARA,
talked about their unease or just mentioned that it had some Church connections.
However, none questioned its secular credentials and did not make allegations on
religious lines. The major concern shown was about the narrow-base such orientation was
providing to the organisation. Yet, in my assessment of the work of the CHC and the
number of people inspired and motivated by the CHC show that its base is much
wider at national level. Perhaps their concern is about its direct interaction and
network at the local level - Bangalore and rural Karnataka.
My comments: The organisations taking firm stand against religious
fundamentalism and fighting against communal violence do invariably face
criticism and attacks from the communal organisations. One way to manage this
pressure is to ensure that one’s activism is pitted against all religious
fundamentalism and communalism; that such things are done in a very visible
manner. The liberal Muslims have always felt pressure to shown equal enthusiasm
to fight the communalism and fundamentalism within Muslim community. The
CHC has done lot on this line perhaps it could be made more organised.
(4) Some disturbing comments were also received. A non-staff member who, while
appreciating greatly the commitment to participatory way of functioning, informed that
he had heard from others as well as from some junior and senior staff members that
decision-making in the CHC was too centralised in the hands of one or two persons and
that there was one individual pulling strings from behind those two decision-makers.
However, he refused to give his source, and since no staff member mentioned it to me
despite my probing, I was not able to validate this information. In another comment, a
former senior staff member felt that organisational environment was not conducive to the
articulation of problems of the staff as it was looked down upon as trade union activity,
and as a consequence, some of the staff members could never make their grievances or
views heard. He also felt that there was not much encouragement to bring together staff
on non-work basis - like picnic, cultural events. At least two other persons - one former
staff member and one who spent few months there getting initiated to community health
made critical remarks of the issue of participation. One of them called the environment
paternalistic, and thought that it was useful to begin with but as one grew on the job, it
started stifling. Another called it paternalistic and condescending, and thus, participation
was at the mercy of the need of the top leadership rather than as a need of the staff. These
three and two others who had worked with the CHC (as staff or as trainee), and one
senior staff member commented about the lack of autonomy in work, and that being
justified as the need for participatory functioning.
My comments: The perception of the way organisation and its leadership are functioning
are difficult to comment on. In the best of the situations, the individuals have made
insinuations or thrown aspersion on characters of individuals. But these perceptions
provide pointer to the need for refining structures of the organisation and for
strengthening certain organisational processes. But this is easier saying than done. The
best way of doing it is by making the constituency that is complaining - mainly staff
- to sit together on their own and defining concretely the kind of professional
autonomy they need; the way they want to do their own things, make mistakes and
'earn from them; and the kind of transparency they want in the organisational
decision making. On the last issue, it may help if the decision making process is
shifted from broadly participatory to making a staff committee specifically
responsible for decisions taken.
(C) STRENGTHS AND WEAKNESSES
My notes on the interviews provide a very lengthy list of strength and weaknesses. I
suspect that I was told more about weaknesses than the strength because - as one person
put it - “it will be easy for you to put together strength because generally CHC has an
excellent history, but there is less critical reflection on weaknesses as not many would be
ready to be very frank about them or they just do not want to hurt”. On the other hand, for
each response on strength I found another response that characterised it either as
weakness or recent erosion of the strength. As a consequence, it was not possible to
separate out strength from the weaknesses and vice versa. In a way I felt that this was a
much better situation, as it is not possible to look at anything in terms of only positive
and negative, but identify positive as well as negative in each aspect of the work of
organisation. Thus, given below are the issues raised and the range of responses
characterising them as strength or weakness in a dynamic manner.
H) The most important strength highlighted very frequently is its long tract record
of work of last 20 years. Even those who left the organisation acknowledge the
commitment and sincerity of the CHC though they have other criticisms of the
organisation. This track record, its survival of two decades, the amount of
inspiration it has provided to individuals and organisations, the support - both
moral, intellectual and material - it has provided to otherwise weak movements
within health sector, the interaction and networking it has promoted, made more
and more people to look at the social aspects of health, the advocacy it has done on
some crucial issues, the good will and respect it has gained in the circles of activists
as well as policy makers, and so on - the list is too long to mention - have given the
CHC a national profile and prominence. An overwhelming majority of the persons
interviewed and those who responded to a questionnaire, including its critic, described
this as the biggest strength of CHC, and a base and potential on which the organisation
can embark on its next phase of development.
I fully agree that the CHC is at a stage when it can consolidate its national network
and motivate it to make useful contribution in building an institution of learning
and action at national level.
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(4) Community orientation of the first several years was mentioned as the strength but
some others were feeling concerned about reduction in the community orientation in last
few years. Interestingly, those who felt that the future of CHC was in undertaking more
research and policy advocacy did not mention much about the reduction in community
orientation but those who felt that it should go back to the original work of training of
NGOs were emphatic in saying that the direct work with the community has suffered.
The same respondent with the latter view went to the extent saying that the NGOs that
were close to the CHC have moved away though not broken away from it, the change
was dictated more by the change in the orientation of the leadership - read, Ravi and
Thelma - than the change in the priority at the ground level. They also felt that the
current priorities are gradually turning its strength in community work into weakness
This group suggested that CHC should opt for a mix of consistent community work and
institutional development, and should have less concern for organising “events” than
actually forging alliance based on common work.
My feeling is that it is very difficult to judge whether “new” work on health policy is
additional” or at the “expense” of ongoing community work. The work on health
policy by the CHC, in strict sense, is not new, it only become better organised and
consistent in recent time. Such work does make the organisation to divide time but
that does not automatically mean that in absolute terms the community work has
declined. What is more important for the institution is not to debate whether there is
“shift” in emphasis from community work to health policy work, but to discuss how the
research, action and advocacy are balanced to further the impact of the organisation For
me it was impossible to assess “impact” of the community work of the recent past. Such
evaluation is of totally different kind, and demands good data of the base-line to make
comparison. I did not want to pass on impression as evaluation, so I have avoided such
inquiry. But I have no hesitation in saying that mere community work is going to be
less effective and sustainable than the community work with strong research and
advocacy component. Hence irrespective of whether the critics are right or wrong in
asserting that the community work has declined, I would suggest that the CHC
should go for a more balance approach among community work/action
research/training and advocacy.
(5) On one hand some members of the SOCHARA and some of the trainee fellows felt
that CHC relies a lot on “inspiration” and “individual motivation”, and that on its own
such administrative methods were the best. On the other hand there was a feeling that
when an organisation grows, it is difficult to rely only on inspiration and individual
motivation and that one needed better system of administration. Some pointed out as the
weakness the lack of administrative and programmatic decentralisation, nebulous and not
open to specialisation, kind of division of labour, is less sensitivity to the fact that all
individuals might not have enthusiasm for all activities, and so on.
On probing, I found that there is some degree of division of labour and specialisation
already there but there is a tension related to accepting as a correct process - there is
constant looking back about the desirability of such development thus making it very
tentative and not allowing it to settle down. The organisation needs to make peace at
some level or clear misconceptions prevalent about the issues of specialisation and
professionalisation as a part of integrated functioning of the organisation. Along
with this there was a concern for taking too many issues - the desire to respond to as
many requests as possible rather than focusing on the programmes at hand and
doing best in a focused manner. This problem needs to be addressed by, as
suggested elsewhere, relying more on the discussion papers and the plan outlined
there and also by using some basic criteria on responding to requests.
(6) There was lots of appreciation of the work of networking. Almost all felt that such
networking initiative of so many years was a real plus point, and it has made many
organisations conscious about their need to do work in the field of community health. At
the same time, they and others felt that networking on the long-term basis would yield
better dividends if the networking is combined with three important “in-house” functions
or works, viz. (a) capacity building within the staff of the CHC, (b) some outstanding
outputs from the CHC staff, and (c) CHC having its own field area of work. They felt that
by networking the CHC had contributed a lot, but beyond a point its moral authority in
the network was non sustainable if it did not have its own development and team of staff
that is seen to be doing good work of its own. Two former senior staff members felt that
excessive networking sometimes made the leadership ignore the in-house capacity
available, it also made them to take less risk with the in-house staff by giving them
opportunity to make mistakes and learn. Another respondent felt that intellectual and
moral authority of the CHC in such network came from only a couple of CHC persons
(Ravi and Thelma) and so the organisation was appreciated less than the individuals. In
their absence, the networks did not take others representing the CHC so seriously
and that was frustrating for the staff. And such professional staff needed time and
space to come out with their own outputs before they were recognised in their own
right.
(7) One weakness that was articulated by several individuals - former staff and others at
periphery - was lack of following up good initiatives. For instance, the contribution made
by the CHC in the task force report of Karnataka was highly appreciated, but at the same
time not doing enough to follow up its implementation by undertaking its own
independent policy research and using other advocacy opportunities (like media,
seminars, conferences, legislative assembly questions etc) with such data, was
characterised as major weakness. Some of these people felt that in past several such good
initiatives from the NGO sector have not achieved desired goal because of lack of
generating pressure for implementation - “comparatively easy to change policy, difficult
to get it implemented”. So more needed to be done on the implementation. Such
weakness in follow up was attributed to insufficient attention to or failures in
organisational development and in-house team building. At the same time, I also found
some differences in perceptions. The positive perception on the follow up was that on
Karnataka health policy the follow up was more in terms of going along the government
in making it to inaugurate changes and to sustain them within the government structures
rather than being confrontationist. In any case, irrespective of the positive and negative
perceptions on the follow up, it is clear that the way out it in having a policy of
taking only certain number of initiatives and following them through; and in
creating in-house organisational capacity to make that happen.
(8) A few respondents were concerned about the fact that there was no clarity on the
“CHC’s identity”. “Is it a campaign team, a scientific team; a platform for few
individuals or an organisation/institution?” Here too the emphasis was on what the CHC
did in-house being as important as what it did outside.
(9) There was very high appreciation of the contribution made by the CHC in
building Jan Swasthya Abhiyan, People’s Health Movement secretariat,
International networking and campaigns, its role in People’s Health Assembly, its
media profiling of the PHM, and so on. One person described such contribution as
“simply great”. Generally, the feeling was that it has done a lot in strengthening
such movements, particularly PHA and PHM. However, this work of last few years
has also attracted some criticism - one repeated by some was; that it has become
more international oriented than to the local work. I feel that its work of last few
years in these fields and organisations is indeed a great achievement and so if there
is a need to balance between the local and international then it can be looked into,
but it should not over-react to the criticism and completely discard its international
work.
(10) I met individuals connected to environment and disaster management
movements and organisations. From both currents I received very high appreciation
of the contribution made by the CHC, and they demanded more such work from the
CHC so that these movements could build their capacity on health issues, in
providing health care and in undertaking research. This indeed is a great strength
of the CHC and it should find ways and means of sustaining it. It needs to be taken
further at two levels, (a) by helping such movements to create capacities to
undertake studies or investigations on health impact of environment and disasters,
and (b) contribute to their work and movements by doing systematic research in
health and environment and disasters.
(D) PROGRAMMES AND IMPACT - CONTRIBUTION OF THE
CHC/SOCHARA IN VARIOUS FIELDS. IMPACT
Many of the major responses about CHC/SOCHARA’s impact have been covered in the
critical remarks on the its strengths and weaknesses. It must be re-emphasised that
most of the respondents were very clear about its general impact. The differences or
criticisms were usually with regard to the extent or degree of impact. Some key
criticisms were based on the assertion that the impact was great, but its
organisational capacity to sustain the impact in order to affect a major or long-term
change was limited.
K
In addition at least on two issues, the environment and disaster management, I could meet
the individuals and organisations concerned and could get first hand information on the
way the contribution of the CHC was appreciated. The third category of work was on the
O training and I could meet individuals from three NGO or NGO-networks who
testified on the positive impact of CHC’s training work on the capacity building for
undertaking community health work and in brining community health on their priority
agenda. It should be noted that the CHC training has helped both the health NGOs as well
as non-health NGOs.
The third source of my information for understanding impact is based on meeting some
community level workers of another NGO collaborating with the CHC project
Interestingly, the project work of the CHC on different issues taken up in last few years is
norma ly done in collaboration with some community-based NGOs, usually not having
health as its priority area of work. The CHC does not believe in establishing its own
direct community work but believes in doing it in partnership with an established
community level NGO. This provides them with good base for intervention and
reduces duplication of work of another organisation and at the same time helps in
building capacities of the community based organisation that is going to continue its
work in the community even after the CHC project gets over. I met community level
workers collaborating with the CHC in its project on alcohol and found that the
partnership was well established and there was mutual trust. However, I also found that
this limited the amount of innovation in the approach and strategy that CHC could take
up as ultimately it is required to implement its project within the organisational
constraints of the existing NGOs.
As a part of the review exercise, the SOCHARA/CHC sent out a questionnaire to large
number of individuals in the country. Some of their responses testify to the impact made
by the CHC’s work. Some relevant responses are given below:
Impact and recognition as a centre:
- “It is an important centre for community health in India”.
- “Despite ... bleak scenario of voluntary organisations, the CHC is an
outstanding example (having) continued to serve the PEOPLE’S sector in spite
of considerable difficulties
The CHC has played a seminal role in advocacy
not only at the people’s level, but also at the State, Central as well as
International levels, especially in the WHO. ... The CHC
now claims both
national and international recognition. Their efforts need greater
acknowledgement and support”.
“CHC has been the most active group in critiquing and advocacy in medical
education.”
CHC has been able to create a platform .... to view health as a justice issues
provides opportunity to learn to integrate the social, economic issues with
promotion of health.
Has symbolized ... (as) an organization truly dedicated to taking up causes and
spreading awareness on public health issues and problems in our country
Over the years has maintained its credibility and integrity and therefore
lay-persons have been able to use information, views, messages on issues,
expressed by CHC - with complete confidence.
CHC has documented effectively in a number of areas
has raised its voice
on many issues to be heard
The follow through has not been focused
enough to produced specific results
Appears to be capable of being India’s
best advocacy organization, yet is involved in too many areas to produce
effective results.
I trust CHC to represent my/our concerns when it works at policy level or at a
global level. ... it epitomises a belief that you don’t have to become big to do
something big. And that professionalism has to be maintained even at NGO
level
Its greatest strength lies in preventing people from feeling threatened
in a network - their networking skills are excellent.
CHC counter balances the commercial aspects of community health. ... gives a
forum to people who view health through an alternative perspective and gives
(2) How should these three functions of the organisation be continued under one
organisational structure of the CHC? To me this is a practical issue and not principled
one. If the individuals running the organisation are able to respect all three functions
equally and able to evolve an organisational structure that is conducive for coordinated
functioning, they all could be done under the CHC. But any approach that
unnecessarily pushes the researcher to constantly feel that because they are
researchers they are elitist and to overcome their elitism, they need to compulsorily
do some community work would create tension and may jeopardise the smooth
relationship between the three functions. Same way, the arrogance of researchers
attaching low importance or priority to the action based community work could
lead to similar outcomes.
My suggestion would be to choose from two possibilities:
(a) The CHC may be kept as one unit under one coordinator, but with functional and
administrative decentralisation between the community-based training, campaigns and
action on one hand and the research and public health training on the other. Each of these
two arms could be headed by a joint/deputy-coordinator. This would promote division of
labour and specialisation, but would have same administrative support.
(b) Alternatively, the CHC could continue to function as the unit of SOCHARA for
community-based training, campaigns and action - with strong component of the work as
catalyst etc. But the research and public health training may be separated out as another
unit of the SOCHARA. This unit could be called by any appropriate name, but it will
work separately from the CHC but will be supervised by the SOCHARA.
A BRIEF REPORT ON THE VISIT TO CHENNAI OFFICE OF CHC: 21 NOV 08
--K Gopinathan
Introduction
After the initial discussions with the Chennai Team in Bengaluru on 01.11.08. I had planned to visit Chennai on
14.11.08 (the date accepted by all ) for further discussions. But this could not take place because of some urgent
engagements of two of the members of the team on that day. Tried to advance the visit to 13 Nov 08 for the
convenience of the team but had to give up owing to unavailability of train accommodation. The visit was then
postponed to the last week of Nov (provisionally 27,h) with the intention of meeting with all the members of the
team for obtaining a common perspective of the situation. Later on. when contacted to confirm the date, it was
informed that the team member who was away from the country will be back only on the 27th night and meeting
with them on that day was not possible. The next day could not be confirmed. Moreover 28th was not
convenient for me. The meeting with the other two members of the team was therefore fixed for the 21st Nov 08.
Accordingly this visit was made.
Amir Khan met me at the train station and took me to Bala Mandir where my accommodation was arranged.
We reached there at 8.45 am. The office of CHC team is located in the premises of Bala Mandir.
Amir went to his residence for a wash after fixing the meeting time as 10.00 am. I requested him to inform
Shalini about the same.
The Office
There are two rooms facing a narrow corridor. The rooms are with inadequate ventilation and light. One room is
kept empty. It is difficult to enter the currently occupied room because the doors of it cannot be easily opened or
closed. One of the doors does not open and the other opens little more than half just enough for a person to
enter.
The rooms do not seem to have dusted or cleaned for days. Dust collected all over the tables, racks, files, chairs
and other places of utility. Toilet area may not have been cleaned for weeks as it appears. There are cobwebs,
insect nests (wasp), stain and so on.
It was informed that a lady working with Bala Mandir has been engaged to carry out the cleaning work—of the
floor only. Dusting of tables/chairs/files/racks/cupboard/printed material kept on the floor has not been done for
days as has been observed.
There are three office tables and three plastic netted chairs with steel tube frames. Of the three chairs one cannot
be used for it has gone out of shape. Two tables are kept in the center of the room and the other in a corner.
There is a PC with a telephone and internet connection as also a printer. A few cups and steel plates are seen
lying on top of an almirah.
A “'COMMUNITY HEALTH CELL (CHC)" panel has been nailed to the door frame of the office facing the
corridor. It could have been at the entrance of the building with full address indicating office hours (if it has to
be considered a full fledged extension unit).
As is seen today at the most the present arrangement could be termed a meeting place. A lot of changes have to
be effected to make it an extension unit of CHC (as 1 understand from the discussions with the team it is no
more a project office).
Suggestion for improvement:
1.
could engage someone to carry out dusting/cleaning of office/corridor/lavatory every day.
2.
painting/coloring of office and corridor could be taken up
office door and other furniture may be got repaired
1
4.
it would have been better to take the first room (at the entrance to the building) and the immediate
second instead of the present second and third room. There are a total of four rooms, of which the first
and fourth are vacant.
5.
arrangements for adequate lighting of the rooms/corridor may be made
6.
a name board indicating as extension unit of CHC with full address, office hours to be put up at the
entrance to the building
7.
a full time assistant could be appointed to carry out office work including attending to enquiries,
visitors and so on
8.
the tendency of every team member opting for flexi hours of working to be curbed. Such facilities may
be extended to most exceptional members of staff (a policy to be framed).
The Discussions
The discussions began at around 10.30 am.
Outcome of discussion in brief:
|the outcome mentioned herein is based on the response to questions put to the team. My suggestions are
indicated in italics)
I.
The office facilities available in the office are sufficient. However some improvement could be made in
terms of upgrading the present PC, making available laptops, computer table (the present one is small and not
comfortable), scanner and further furniture, appointing a full time office assistant.
HO to examine this issue.
The activities are in accordance with the plans made at the HO along with the team in Bengaluru. The
staff development workshop is not of much use. It goes as administration related meeting. Individual-wise work
is focused. Though the team has expressed the need to meet the seniors in the HO for sharing of
experiences/ideas/plans while in HO. it was not possible. Nor attempted. Unavailability of time was stated to be
the reason. However it is said that such meetings are taking place in Chennai (not mentioning with whom).
The members of the team together have to prepare a plan before making the visit so that it could be
utilized profitably. This could include meetings with the seniors within and outside of CHC (an inadequacy
identified) and the administrative team. For the purpose, if necessary, an extra day could be spent in
Bengaluru.
The team is familiar with the objectives of SOCHARA. It is aware of the Rules, regulations,
procedures and guidelines of the organization but not being strictly complied with.
Administration to look into this matter.
4.
Rakhal is in charge of the Unit and he oversees the functioning. Amir maintains imprest cash. Activity
report and statements of accounts are sent to HO separately. There used to be delay in attending to these but it
has now been minimized.
It would be preferable to send the statement of account and the report of the activity/activities for
which money had been expended, together. This will help in monitoring of the activities and of the related
expenditure. [It is informed that the imprest amount sanctioned is Rs 10,000.00.1
5.
The team informs that it contributes to the furtherance of the objectives of the Society in various ways
at individual level—like participating in the program of a personal contact or helping a personal contact in
preparing a document.
Attempts should he made to convert this personal contact in to organizational contact.
2
6.
The team has been discussing the ways and means of generating funds for the activities of the
organization.
This should be encouraged; guidelines to beframed.
7.
With regard to a question on accountability nothing much was forthcoming. But the team understood
the issues related to it.
8.
The mode of communication is generally phone, meetings, occasional emails (between the members
the team and among the team in HO). Similar means of communication is being followed while dealing with
other contacts including government authorities.
For maintaining proper records, communication with external agencies should always be in writing
especially so with government authorities, using organization letter pads. E mail communication with
authorities should be followed by sending a hard copy.
9.
There is a delay in crediting the salaries of two members.
The A O may took into this matter.
The discussions ended at 1.45 pm because Amir had to board a train at 2.30 pm to Erode for attending to some
personal work. Shalini left the office by 2.30 pm after lunch to attend to some qrgent official work being
attended to from home. 1 remained in the office.
Closed the office door with the help of watchman Sri Kannan. locked the room i
and handed the keys to the office
of Balamandir and left the place at 3.45 pm when Rajendran came to see me and take me to the train station.
Hyderabad
25.11.08
3
COMMUNITY HEALTH CELL
TYPES OF EMPLOYMENT TO OFFER
An organization hires the services of
following lines:
persons for carrying out its functions on the
1. when a created position as per the requirement and as approved by the Governing
Body and included in the
budget estimates is notified for filling in; (permanent
position)
2. when an existing vacancy has to be filled in; (permanent or temporary)
3. when a position is created to handle a specific project/assignment that had come up
during the course of a
financial year and not as a pre-planned and budgeted for but
on an exigency basis;(may or many not be a permanent position in the long run but
could be to implement a project for a specific period, say one year or two years or
three years)
4. when a leave vacancy of a longer duration has to be filled in; (temporary)
5. when an additional hand has to be taken in
(temporary short term)
to complete a time-bound task;
6. when a part-time job has to be handled; (the job described/involved is permanent
and ongoing were the appointee has to be present every day at particular specified
hours but a full time position is not required to handle it)
7. on a contract basis for executing a specific task. It could be for a short period or
long period. The aim is to reduce long term financial burden.
F
Methods of remunerating the employees:
1. Permanent:
A permanent member of staff is eligible to receive salary and allowances and additional
allowances, if any, as per policies of the establishment; all the employee benefits,
facilities, rights and responsibilities (of workers) as per law.
2. Temporary:
A temporary employee is eligible to receive salary and allowances, employee benefits,
additional benefits as described in (1) above. Such employees may have been appointed to
fill up a permanent vacancy in which case they are normally paced on the rolls of the
establishment like that of permanent employees but their services are considered under
probation period in the organization—ranging from six months to one year to two years.
Their continuance in the service or otherwise at the expiry of their probation period
depends on their performance during their probation.
However, at times the establishment hires the services of person/s on a temporary basis in
anticipation of
possible vacancies in that specific cadre in the future. Such
employees may or may not receive full benefits, excepting those that are mandatory, and
their regularization in the employment will arise only when post/s fall vacant. Otherwise
their services will automatically get terminated at the expiry of the specified period or
earlier as the employer deem fit. If the services are renewed it will be with new terms and
conditions and normally such employees will have no right to seek regularization of their
positions.
3. Ad hoc appointments:
Ad hoc appointments are purely temporary in nature and they are focus specific. This is
being resorted to when an emergency situation arises where such appointments cannot be
postponed. It is normally done while, say, providing relief to victims of calamities—
natural or otherwise. Such appointees are paid consolidated salaries, more than that of a
regular employee in the same cadre—could range from 15-25% more-with specific terms
and conditions. This is because they do not come under regular employment of the
organization and therefore they are not given the employee benefit of a regular employee.
In other words higher emoluments are given as a means of compensating the loss in the
form of other benefits. Moreover such appointments are terminable at any time during the
period of employment—whether it is due to underperfonnance or abrupt end of
involvement or any other reason.
i
Justification for higher emoluments:
Adhoc appointees invest their time and energy for the sake of their employers while not
excepting the benefits being offered to regular employees. For instance, a regular
employee is eligible to become a member of EPF, eligible to receive other benefits
including gratuity (after serving the minimum required number of years for eligibility).
PF is currently 12°/o of salary and gratuity 50% of salary for every completed year of
service. Hence it is put as 15-25%. Suggestion: 15% minimum and from 16%> up to
25% as negotiated.
4. Fixed term assignment:
At times the organization finds it difficult to identify a suitable person to handle a specific
job because of unavailability of such candidates or because of the remuneration being
offered is much lower than the market rate. Under such circumstances, it will become
necessary to appoint persons (who fulfill the requirement of the organization) with
negotiated terms and conditions that are different from the existing policies of the
organization so that the programs of the organization may not suffer. Their remuneration
shall be on par with market rate or somewhat near to it.
Fixed term assignments are normally offered to most exceptionally qualified, experienced
and suitable persons [who may sometimes be invitees to take up such positions] at senior
levels.
5. Contract appointment:
The organization may require the services of a person on a full time basis to undertake a
specific job and the organization may make policies to fill in such vacancies on contract
employment basis with fixed remuneration and specific terms and conditions. Their
remuneration may be on par with similar cadres in the organization (or even below). The
services of such appointees can be terminated if their performance is found not
satisfactory. [This is opted mainly with a view to reducing the long term financial burden
of the organization like gratuity, pension. Certain schemes like Provident Fund, employee
insurance will however apply. Many organizations in the country practise this method of
employment.
[such contract employee need not be a direct appointee but a person hired by another
agency and deputed to the organization on specific terms and conditions for performing a
desired task; in this case the employer of the contract person would be the agency who
originally hired him/her and as such the compliance of laws relating to employees/
employment will be applicable to that agency.]
6. Part time post:
It may be that the institution has a regular ongoing activity and to undertake the same a full
time person may not be required but a person on part time would suffice. For instance
teaching of local language to a group of students doing social work studies. In such
situations the organization may appoint candidates to carry out this particular assignment
on hourly or part time basis—say two hours a day or half a day per day. Their
remuneration could be calculated on pro rata basis or 50% of the remuneration (all
allowances included) normally paid to such a cadre plus 10-15% of pro rata payment or of
50%
remuneration as the case may be as compensating differential to motivate
acceptance of the job offered.
Part time employees are normally not eligible to receive any other benefits.
Justification for 10-15% increase:
Employees holding part time posts are not eligible to receive the benefits that are offered
to full time employees. For example: EPF contribution or full travel allowance or paid
leave of absence or any other schemes. At the same time such employees are also
contributing to the efforts of the organization at a greater personal risk than otherswhen viewed their future.
-K Gopinathan
Hyderabad
25 Nov 08
Organisational Reviews of
SOCHARA-2008
/
by Organisational Review Committee
Mr.K.Gopinathan,
Dr.Mohan Isaac &
Dr.Mani Kalliath
(SOCHARA members)
ADMINISTRATIVE AND ORGANISATIONAL REVIEW OF SOCHARA
PRELIMINARY
The Executive Committee of SOCHARA in its meeting held on 27 Oct 08 formed a Committee to conduct an
Administrative and Organizational Review of CHC (as of now CHC is referred to as parent organization in
order to keep the long standing identity though ideally it should have been SOCHARA).
The Committee consisted of Dr Mohan Isaac. Mr K Gopinathan. Dr Mani Kalliath. Dr Thelma Narayan and Dr
H Sudarshan. It was decided at the said meeting that Mr Gopinathan be requested to do the ground work in
consultation with Dr Mohan Isaac and other Members of the Committee.
[Mr Gopinathan has since accepted to be a part of the Committee and agreed to undertake the ground work
related to the review with specific terms of reference.]
2: PRELIMINARY DISCUSSIONS
In connection with this review Mr Gopinathan visited CHC on 30. 31 Oct 08 and 01 Nov 08 and held
preliminary discussions with Mr E Premdas (Coordinator, CHC), Dr Thelma Narayan and Dr Ravi Narayan (the
two immediate past Coordinators of CHC), after which he framed a simple methodology for the proposed
review. The methodology was:
1.
2.
3.
4.
Discussions with the current Coordinator and the two immediate past Coordinators of CHC
Interactions with a few members of staff - two phases if necessary
Visit to Office of the CHC project in Tamil Nadu for interacting with the staff stationed over there for
undertaking the activities and programmes of the organization
Review the functioning of the members of staff of the Tamil Nadu project, look at the systems and
structure of the project over there and suggest possible changes in terms of its functioning and related
matters
The first step the Committee took for executing the terms of reference, after holding discussions with the
Coordinators (present and the two immediate past) was:
a.
to define Cell or Centre/Extension Unit or Extension Office or Field Unit or Field Office
/Branch/Prqject Office
b.
to study the present system and structures of SOCHARA as they relate to—
—CHC (parent institution) along with CLIC
—CPHE and its Field Resource Centre/s
-Tamil Nadu project, the members of the team implementing the project and their relationship
to the parent organization
a. DEFINITIONS (for the purpose of arriving at an appropriate nomenclature for the functional structure of
SOCHARA)
—Cell or Centre or Wing is a Functional Unit of the organization created by the general body of the Society for
effective attainment of a group of objectives or a particular objective.
--Extension Unit or Office/Field Unit or Office: It is a place from where extended activities and programs
related to a formal functional structure of the organization, established elsewhere for the attainment of a specific
objective, are undertaken.
—Branch: It is a.Division of the Society from where, for operational convenience, it carries out almost all of
its business activities, as they target a particular region or State or some arrangements like that, as per the
policies and decisions of the parent organization.
-Project Office: It is an office from where a particular time-bound project is implemented.
1
3: REVIEW OF THE PRESENT SYSTEM AND STRUCTURE OF SOCHARA
The general body of SOCHARA is the supreme authority. The general body consists of a. ordinary membeis, b.
ex-officio members; c. institutional members; and d. honorary members. Ordinary members. Ex officio
Members and Institutional Members have voting rights.
Every year the general body with voting rights elects office bearers and members of the Executive
Committee, except the Secretarv, from amongst themselves during the annual general body meeting.
The Executive Committee consisting of President. Vice President, Treasurer, Secretary and 3 Members looks
after the work of the Society.
The Executive Committee appoints a Coordinator for the Society who shall be an ex-officio member and shall
be the Secretary to the Executive Committee. The Coordinator, who is a paid functionary, coordinates and
manages the activities of the Society under the superintendence and control of the Executive Committee.
The Coordinator is also the CEO ot the Society.
The Society has established one Functional Unit called Community Health Cell to promote and conduct all its
aims and objects and activities. The Society has been appointing Coordinators for the Cell, whenever required,
to manage and coordinate the affairs of the organization. It now has a simple structure with one Functional Unit
headed by a Coordinator.
The organization structure as of now:
General Body
Executive Committee
Coordinator for Community Health Cell
(who is also the CEO of the Society and Secretary to the Executive Committee)
Sub Functional Units (with personnel linked to them)
-Community Health/Public Health Action. Training and Networking
-Community Health Library and Information Centre (CL1C)
-Public Health Policy and Advocacy (now named Centre for Public Health and Equity)
—Support services (administration and accounts)
SOCHARA registered on 16 April 1991 at Bangalore is a legal entity under the Karnataka Societies Registration
Act. 1960. For the purposes of governing the organization, SOCHARA follows the said Act and the Rules
thereon (as amended from time to time).
The Society has framed its own Service Rules/Guidelines related to its staff functioning, leave policy, salary
policy, accounts and finance, staff benefits (in service and retiral).
4. DISCUSSIONS WITH (A FEW) MEMBERS OF STAFF
Members of staff are overworked. There is inadequacy of staff both in Bengaluru and Chennai. AO is over
burdened.
Chennai team is doing good except in the case of timely reporting of activities and sending in of the statement ot
accounts though improvement has been shown over the past few months. Administrative support except
providing office facilities not being extended to Chennai team. Activities of the team in Chennai are in line with
the plans made in consultation with the Bengaluru team, deviations if any being communicated over the phone.
Visit of head office team to Chennai office rare. The team in Chennai contributes to the furtherance of the
objectives of the Society in the form of extending support to like mind individuals and agencies. Such support,
however, is at individual level. The team is discussing various ideas for generating funds for the activities of the
Unit.
2
There is an efficient administration team but communication among them is poor because of which delay takes
place and needs reminders. Administration needs to be pro active.
Upgrading of skills and developing/acquiring new skills would be of value.
There exists communication gap among the members of the team leading to dissatisfaction. Every member of
staff knows the rules, regulations, procedures/guidelines of the Society but sometimes not being followed in
toto. Known contacts are more acceptable to the team.
There is a need to strengthen the functioning of'CLIC and widen its scope.
The Chennai team’s communication with its contacts in Tamil Nadu—government and others
of email and verbal. And among the team members it is through phone and occasional emails.
are in the form
There is a need to share ideas/plans/experiences with the seniors at the HO.
SUGGESTIONS FOR IMPROVEMENT/CHANGES
’ I out and determine the number of additional members of staff to be
4.1 A job assessment could be carried
inducted—temporary or permanent or part time as the case may be.
4 2 Delegating authority at various levels will solve some of the problems. By so doing delays can be checked,
communication gap bridged, responsibility owned, delays curtailed, efficiency improved and effectiveness felt.
4.3 Communication with all the contacts should ideally be conducted by using office letter pads. Email
communication may not be given the due importance especially by government authorities unless the
communicating organization is known to them. If the organization has to be recognized and show its presence in
a given area communication on letter pad would be of great help. The Chennai team may look into it.
4.4 Upgrading of skills and encouraging acquiring of new skills for the members of staff may be thought of.
This will be of use to both the employee and the employer especially at this point in time when the institution is
in the process of widening its operations.
4.5 The senior members of staff may spare a little bit of their time with juniors for sharing of
ideas/plans/experience. Planning a meeting with them in advance would be of help so as to have a relaxed
discussion. The Chennai team could stay an extra day in Bengaluru for the purpose whenever they visit the HO.
4 6 Currently the Chennai team is utilizing the rented office premises—that too partly at the most as a team
meeting venue. This should not be so if we have to treat it as an Extension Unit of CHC. The team should
follow office working hours and at least one of them should be available in the office to attend to enquiries and
making the presence of the organization felt. [With regard to flexi working hours being followed by the team a
policy has to be framed.]
REVIEWING THE CHANGES IN THE WORK AND PRESENT SYSTEMS
AND STRUCTURES OF CHC AS THEY PERTAIN TO:
CHC ALONG WITH
CLIC; CPHE; CHC’s TAMIL NADU PROJECT EXTENSION UNIT
5:
5.1 COMMUNITY HEALTH CELL AND ITS STANDING IN THE EYES OF THE LAW
Community Health Cell (CHC) is considered parent organization. Technically and administratively it is
different. It cannot be called the parent organization because it is SOCHARA which established Community
Health Cell (refer aims and objects of SOCHARA—3.1.j.). Community Health Cell has no legal standing but
the Society has. The Coordinator is the CEO of the Society and not the Cell. It is SOCHARA which has been
granted FCRA Number. Income Tax authorities see SOCHARA as the organization. So is in the eyes of the
Registrar of Societies.
Currently CHC is the one conducting all the activities for achieving the aims and objects of the Society.
In the circumstances a separate independent Functional Unit cannot be formed within CHC. If it is formed it
can be considered only as a sub-unit of CHC. Therefore. CHC to be considered one of the Functional Wings of
SOCHARA to carry out specific objectives.
3
r
Implication I: To suitably amend the Memorandum of Association of the Society
5.2 CLIC
At present CLIC is a part of CHC. However, if major part of its currently available resources are to be utilized
bv another independent Functional Wing. say. CPHE it could be made a part of it (CPHE). Over a period of
time—may be a year or two-CLIC could be made an independent Wing for by the end of this period it will be
known as to how things are shaping. Widening the scope of CLIC. upgrading the skills of its team, introducing
technology to its functioning and bringing in expertise could be thought of. It is not advisable to immediately
start a separate Wing for CLIC as the collection now is smaller, the activities are not even minimal, technology
related programs have yet to begin, suitable leader is not in place to oversee the functions of a contemporary
information center and on top of these, its sustainability and viability cannot be visualized right now in the
absence of a proper study on the matter.
It
It is
is for
for the
the EC
EC to
to decide
decide as
as to
to which
which Functional
Functional Wing
Wing will
will run CLIC based on proportion of utilization as
mentioned above. Upon such a decision, the member of staff currently with CLIC will be attached to the Wing
.. » new Wing. The other Wing may
which has been specified to run it. The budget for CLIC will be prepared..by the
ng expenditure of CLIC.
be asked to contribute a certain amount of fund to the development and runnir^.
A Library Committee could be formed to support the functioning of CLIC.
Implication 2: Policy decision on the running of CLIC including financial and administrative input
5.3 COMMUNITY HEALTH CELL EXTENSION UNIT—TAMIL NADU
For the last three years CHC has placed three members of its team in Chennai to carry out similar activities; as
indeed is a good move-to expand its operations nationally. Since the team is
that of in Karnataka. This
.
are
similar to CHC in Bengaluru, it can be considered an Extension Unit. However,
conducting activities that
before formally naming it an extension unit or otherwise, it is necessary to examine the functioning of the team
posted over there.
The team for Tamil Nadu based in Chennai functions in the following manner. There are three members in the
team each one doing his/her own assignment on a flexi-time basis (has flexi functioning been allowed by CHC
or approved by EC?). A two-room office with basic infrastructure facilities has been given in the premises of
Kamaraj Trust in Chennai (6 kms from Chennai Central). The members of staff do not appear to be working
from this office regularly. It is—one room only-at the most utilized as a meeting place for the team on
Tuesdays and Fridays as can be inferred from the discussions. One of the members of the team is purported to
be going to this office everyday at flexi hours and another member going thrice a week. The members are in
touch with each other almost everyday communicating their whereabouts and activities.
[K Gopinathan visited this office in Chennai and had discussions with two members of the team. A separate
report on this visit has been given to the Coordinator of CHC.]
If the arrangements made in Chennai are to be treated in line with an Extension Unit it is necessary that the
office is made functional as per rules of SOCHARA. One of the aims of creating an extension unit outside of the
main functional unit is to show the presence of the organization in a specified place/territory. If all the members
of staff are carrying out their assignments on a flexi-time basis it will not serve this purpose. Also, it is difficult
to monitor the activities of personnel with flexi working hours.
Flexi hours are advantageous to the employee concerned. It cannot be extended to all members of staff in an
organization especially to those whose primary responsibility is to deal with government officials and other
similar functionaries. In exceptional way only flexi hours of working can be extended.
Therefore, in order to name an Extension Unit of CHC in Tamil Nadu it is mandatory that the office over there
functions during normal working hours. Otherwise the very purpose of locating an extension office in Tamil
Nadu will be defeated.
4
[It has to be kept in mind that SOCHARA has been established with the aim & object of working with the
people involved and interested in community health and development issues. The services of an extension unit
should be made available to any body who approaches it—could be government or other agencies. This can be
attained only by making its presence during normally accepted working hours.]
Structurally the Extension Unit will be seen as a sub-unit of CHC and as such it will be the responsibility of
CHC—the functional wing—to allocate funds for running the unit.
Implication 3: To define Extension Unit and suitably amend the Service Rules to allow flexi working
hours in exceptional circumstances.
6. CENTRE FOR PUBLIC HEALTH & EQUITY—FORMATION OF
It is CHC which has been undertaking the activities and programs related to the aims and objects of the Society.
CHC has involved itself with various activities for the attainment of the aims and objects of the Society.
However, owing to limited resources—human and financial—it could not engage itself actively for promoting
certain priority objectives. A time has come to do that. Accordingly a new Unit and an Extension Unit within it
with independency in functioning have been formed and started working with visible changes—both technical
and adminstration-wise.
[Organizations adopt different structural patterns such as this at different stages of its lifecycle. It defines the
reporting relationship, facilitates allocation of resources, delegation of authority and decision making. Such a
Centre so created will also facilitate coordination and smooth intertwining of employees and communication
and administrative systems of the institution.]
The newly formed units and sub units have now to be formalized with the necessary changes in its working,
reporting relationship, delegation of authority, allocation of resources, decision making etc. While so doing
there will be a few implications. Those implications have to be overcome appropriately for the smooth
functioning of the members of staff and the systems thereby. The expected implications are given below:
Implication 4: Need to amend Memorandum of Association of SOCHARA
One of the Aims and Objects of the Society is “ to have a Community Health Cell to promote and conduct all
the above activities”. Here “all the above activities” means the aims and objects. It is clear from the
Memorandum of Association that Community Health Cell is a functional wing of SOCHARA, through which
the Society hopes to attain its aims and objects. Therefore, creation of a Centre independent of CHC invites
amendments to the Memorandum of Association specific to creation and running of different Wings.
Specific Units within Wings could however be formed since such formations are for operational convenience
only.
Units within a Wing do not require amendment to the Memorandum of Association as they are formed for
operational convenience. However, it is advisable to state the same in the Memorandum of Association if such
Units are to be formed outside of the jurisdiction of the Registrar of Societies, Bengaluru District under whose
seal SOCHARA has been registered.
6.1 STRUCTURAL AND ADMINISTRATIVE CHANGES
Implication 5: A leader to head the newly created Wing
A separate Functional Wing to promote a specific objective requires a leader to head it. Such a leader should
atleast be equal in ranking in comparison with the leader of the other Functional Wings. The EC to decide on the
rank considering the technical expertise required of this position.
Implication 6: Change in roles of positions—amendments to the Rules and Regulations of the Society
In accordance with the Rules and Regulations of the Society, the Coordinator of CHC is the ex-officio Secretary
to the EC and also the CEO of the Society. In order to pave the way for formalizing the Centre as an
5
independent Unit, it is necessary to suitably amend the Rules and Regulations of the Society as they pertain to
ex-officio members and the Secretary to the EC as also the CEO.
Suggestion I: The Secretary to the EC could be an elected office bearer as in the case of the other members of
the EC. The leaders of different Wings will report to him/her.
Suggestion 2: A CEO could be appointed by the EC to manage and coordinate the functions of different
Wings. This official could be the exofficio Secretary of the Society .
Suggestion 3: The leaders of different Wings could act as Exofflcio Secretary in turns to the extent of fulfilling
the legal formalities pertaining to the Society. The structural reporting could however be to the President or
CEO as the EC deem fit.
6.2 CHANGES IN ADMINISTRAIVE SYSTEMS
EACH WING
INCLUDING PERSONNEL ATTACHED TO
Change 1: Functional independency and delegation of authority
Each Wing to be given functional independency within the aims and objects of the Society and along with it the
necessary authority to carry out the work to be delegated. This will sooner or later will call for creation of sub
units within the Wing and as a process toward it administrative changes are to be effected. They could be: a.
allocation of funds to each Wing; b. authority to the leader to manage and control the funds earmarked; c.
appointment as a member of the team of the Wing an official to keep books of accounts of funds (appointment
could be through skill development of an existing member of staff or through induction of a new one) allocated.
Change 2: Budgeting and Account keeping of allocated funds at different levels—role of central
administrative team vis-a-vis Functional Units.
Currently CHC is supported by an Administration & Accounts team led by an Administrative Officer. This is a
centrally functioning team extending support to all the Wings of the Society with additional hands, if required,
and with changes in the roles and responsibilities of certain functionaries in the team. For example: The
services of Administrative Officer will be available to all the Wings and therefore he/she will be responsible for
all the administrative aspects of the Wing—not the day today work of the Wing—while he/she will have a senior
official at the central level to coordinate account related matters with all the Wings. Each independent Wing will
need to have its own Accounts Assistant to look after the Wing's accounts functions. Accounts functions for
each Wing will be decentralized but reconciliation/compilation of each of them will take place periodically at
central level. So is finalization and reporting.
An internal auditor should be employed to audit the accounts at various levels.
6.3 STAFF POLICIES, SERVICE RULES AND REGULATIONS OF THE SOCIETY
The staff policies, service rules and regulations framed by the Society shall be applicable to all its employees
and all the employees are bound to abide by them.
6.4 SALARY POLICY
Change 3: Special remuneration for special categories of staff
An organization takes to creation of separate divisions/wings/branches/units--as they be called—to carry out
certain specific objectives. To handle the work involved for achieving those objectives it may become necessary
to induct subject experts/specialists. Unlike general experts or non technical personnel it may not be easy to find
them and hire their services for the organization with a lower remuneration compared to the market rate. In
order to attract such talents and retain their services at least for some time, the organization may have to pay
higher remuneration to those specialists compared to generalists. However, it may not be possible for an
organization like SOCHARA to make different salary policies for its employees working in its different Wings
in view of its employee-friendly ethos and values. Therefore, the higher remuneration could be in the form of,
say, teaching allowance, allowing acceptance of consultancy fee, sanctioning sabbatical for earning extra
income.
6
6.5 FINANCIAL MANAGEMENT
Change 4: Constitution of Finance Committee
The volume of funds being handled by the Society is expected to rise upon creation of independent Wings The
EC >s, therefore, required to constitute a Finance Committee (FC) whose primary function will be to review the
financial position periodically, advise on revenue generation, investment and other matters related to
tinance/iinance management.
Ihe^c^lcberS Of thei^n‘lnce.Committee shall include, apart from nominated/coopted members, the Treasurer,
die CEO/Secretary, Heads of each Wing and the Adminstrative Officer. The FC will be a sub-committee of the
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