RF_COM_H_56_PART_2_SUDHA.pdf
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REC0GNI SING THE NEU PARADIGM
This alternative health care project phenemena
has been a
spontaneous upsurge in the last two decades and not an organised
planned movement.
From 1984, a team of us have been studying
this process through a series of reflections with individuals
and groups and network to build a new understanding of
Community Health from field level experience and grass roots
action.
Our attempt has been to look at successes and
failures, strengths and weaknesses, opportunities and threats
of all these community health action initiators.
Also by
taking a ’macro view’ and differences, we have been trying to
build the components of a new paradigm.
The broad definition that is emerging is:
"Community Health is a process of enabling people to exercise
collectively their responsibility to their own health and
to demand health as their right, and involves the increasing
of the individual, family;-
and community aionomy over health
and over organisations, means, opportunities, knowledge,
skills and supportive structures that make health possible"
The components
of Community Health action includes:
Integrate Health with development programs,
Integrate curative with preventive, promotive and
rehabilitative activities,
Experiment with low-cost, effective, appropriate
technology,
Involve local, indigenous health knowledge, resources
and personnel,
Train village-based health workers,
Initiate, support community organisations like youth
clubs, farmers clubs and mothers clubs,
Increase community participation in all aspects of
health planning and management,
Generate community support by mobilising financial,
labour skills and manpower resources.
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2
While facilitating these managerial/technological innovations
the Community Health action initiators have to seriously
face up to a wide variety of 'social processes' and 'value
issues’ that are:
i)
Organisation of non-formal, informal, demystifying
and conscientising 'education for health' programs;
ii)
Initiating a democratic, decentralised, participatory
and hon-heirarchical value-system in the interactions
within the health team and in the health team
community interactions;
iii)
Recognising conflicts of interests and social
tensions in the existing inequitous society and
initiating action to organise, involve all those
who do not/cannot participate at present;
iv)
Questioning the over-medicalised value system
of health care and training institutios and cha
llenging these within the health team; learning
new health oriented values;
v)
Recognising that community health needs community
building efforts through group work, promoting
co-operative efforts and celebrating collectively;
vi)
Confronting the super-structure of medicalised
health delivery system to become
- more poor people oriented
- more community oriented
- more socio-epidemiologically oriented
- more democratic,
- more accountable
vii)
Recognising the cross-cultural conflicts inherent
in transplanting a Western Medical model on a
non-western culture and hence exploring integ
ration with other medical cultures and systems
in a spirit of dialogue.
3
viii)
health efforts
Recognising that community
with the above principles and philosophy
cannot be just
a speciality;
a professional discipline;
a technology fix;
a package of actions;
a project of measurable activities;
but has to transform itself to
a new vision of health care;
a new value-orientation in action
and learning;
a movement, not a project;
a means, not an end
Are these the axioms of an alternative?
These new'issues',
being
'values', approaches to health is now
recognised by a growing number of coordinating
groups, academics and policy research groups as well.
Four coordinating groups among the NGOs including the
Voluntary Health Association of India, The Catholic
Hospital Association of India, The Christian Medical
Association of India and the Asian Community Health Action
Network have all identified with this new thrust in the
policy statements of the 19B0s(
)
The ICMR/ICSSR Health for All prescription includes
these dimensions as well (
)
A plea for a New Public Health is the latest in a series
of issues and thearetical perspectives emerging from
academic centres as well.
However recognising the paradigm is after all only the
first step.
Taking action to build a new structure is a
challenging and daunting task.
Converting the old system
to a new way of life is not going to be easy
HEALTH FOR ALL
ICMR/ICSSR
Prescription
A MASS MOVEMENT
TO
I reduce poverty, inequality
AND SPREAD EDUCATION
H; ORGANISE POOR AND UNDERPRIVILEGED
TO FIGHT FOR THEIR BASIC RIGHTS
M MOVE AWAY FROM COUNTER-PRODUCTIVE,
CONSUMERIST WESTERN MODEL OF HEALTH
as
CARE AND REPLACE IT BY AN ALTERNATIVE
BASED IN THE. COMMUNITY.
EVOLVING POLICY ALTERNATIVES
The National Health Policy statements are beginning to
echo these ideas and values.
Whether this is ’populist rhetoric' or a serious 'rethink'
only time will tell.
NATIONAL HEALTH QQLICY, 1983
Recommendations
For restructuring Health Services
1.
Organised support of volunteers, auxiliaries, paramedical
and multipurpose workers
2.
Selection and training of community health volunteers
3.
Building of self reliance and effective community participation
4.
Establishment of a well worked out referral system
5.
Establishment of a nation wide chain of sanitary-cumepidemiological stations
6.
Concept of domiciliary and field camp approach
7.
Devising planned programmes to reduce governmental
expenditure and fully utilising untapped resources
8.
Setting up centres to provide speciality and superspeciality
services
b
9.
Mental Health care and care of physically handicapped
10.
Priority to unpriviliged and vulnerable section of
society
11.
Ensuring adequate mobility of personnel of all levels
of functioning.
VHAI (
)
\ the cover STORY
\
Community Health In India >
Preamble
brings to the Readers
This story
of Health Action a birds eye view of an emerging
process in India in which there is a growing shift
of emphasis in health work from
Doctors and Nurses
Hospitals and Dispensaries
Drugs and laboratory investigations
surgery and medical technology
to
Village/Community based health workers
Health education/awareness building
Appropriate health technology
Community based health actions
Involvement of traditional healing t -
ns
Integrated rural development
and- m\r-n
The process reflects a growing diccnchantment with the
'
■
■
';'rT
“ ~J
hosoital/institutional based high technology models of
health care which we transplanted and adopted in India
to meet the health needs of our people-.especially since
independence.
The process also reflects a commitment and a growing
diversity of efforts and initiatives all over the country
to adapt, innovate, create, alternative approcahes to
health care that are more relevant to our people-’ s needs
and
social realities.
White it is not possible ■ to
introduce readers to all the participating groups and
initiatives in theCommunity Health Movement we have
..2
2
attempted to explore as much of the diversity as possible
as well as quote from the wealth of documentation, reflections
and educational materials that this ferment is generating,
HEALTH ACTION
July 1989
Theme: Community Health in India
1, Community Health ; Exploring the Indian
Experience
CHC„ Bangalore
2i/Voluntary Agencies in Community Health :
The need for a new paradigm
Alok flukhopadhyay
3'. Community Health : Learning through
our failures
Pram and Hari
John
4; Building Holistic Health Communities
Edwin S.J
5,
Samuel Joseph
^an a Hospital be Community Health oriented?
S, SEARCH: fin experience in Community Health
Research
Abhay Bang
7*./Training for Community Health Care
: A medical college experience
Dara Amar
8. Health of People is Wealth of Nation
Jacob Cherian
9. Community Health : Keeping Trac*;-.
basic Resources inventry)
CHC9 Bangalore
0>'Organ!zing Deople for Health
~ Problems and Contradictions
Anant R S
■ £/f'•/ )-^ErA:'L.Tj+
C.
STAGES IN COMMUNITY HEALTH SERVICES
E
lEADIwL, 7p
MORE
tD^PLt'ic
PRIMARY HEALTH CARE DEVELOPMENT ARE:
Stage 0: Community has to come to the hospital resulting in
limited access to health care.
Stage 1: Mobile clinics which give episodic services unable to
deal with complications developing between the
intervals of care.
Stage 2: Public Health Services which attempt to achieve disease
control without necessarily depending on active
recepient community involvement.
Stage 3: Hospital-based,, community-oriented, Primary Health
Care whe;re all resources and health funcationaiies
are taken regularly and frequently from hospital
bases into communities requesting and cooperating
actively with this assistance.
Stagg 4: Community Based Primary Health Care (CBPHC) with
facilities and health personnel firmly established
in communities requesting them and actively cont
ributing to their implementation.
Tertiary hospitals
are then used only for referrals, training and
assistance as and when required.
Stage 5: Multi-sectoral, multi.disciplinary integration of many
different comoonenfes in each community, leading to
improved health and economic developmemt.
Stage 6: Education, organisation, mobilisation of resources
and active implementation of socio-economic development
of people for their own total health at the micro
project level.
Stage 7: political activity by communities at the macro
'
level to ensure primary health care with the quality
of wholeness in life for all.
(Source: Fiona Plus, A Bi-monthly bulletin on Primary Health
Care in Community Health, )
ALHA ATA - - Tan Years After
A decade age, on September 25, 197B, the Alma Ata
conference formulated at Primary Health Care (PHC) strategy
to achieve "Health for All" (HFA) by the year 2000.
Some
argue that there has been virtually no success and that we
should abandon the strategy.
Others maintain that consi
derable progress has been made and that we only need to
redefine the objectives dightly in planning for the year 2000
In its first evaluation report, WHO claimed that some
progress has been made towards HFA 2000.
Paradoxically, it
is the developed countries that have benefitted most,
Deve
loping countries still have not achieved much success in
PHC coverage.
The obvious success stories, such as the
achievement of 50 percent coverage in child immunization
and the final eradication of small pox, cannot conceal the
wide gulf which still exists between the urban "haves" and
the rural "have-nots".
Nearly 65 percent of people inAlndia
are trapped in the vicious cycle of poverty, malnutrition
and infectious disease, which reduces their capacity to
work and limits their ability to plan for the future.
For
example, 100 to 200 out of every 1000 infants born alive
still die during their first year of life.
In spite of the dismal statistics, some progress has
been made in the decade since Alma Ata, including reductions
in the infant mortality rate, the crude birth rate and the
death rate, and an increase in life expectancy.
The concept
of the community health worker, who is selected by the local
community to serve the community, has had considerable
impact.
Medical education has been re-oriented toward social
goals, hhd the teaching of preventive and social
medicine has been upgraded.
There has been a signifciant
progress in re-orienting the PHC to maximize the use of
limited resources through better management.
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2
4. A community means its members feel with one another.
A community, devoid of feelings, is not yet a community
It may be just a task force.
Community members "weep with those who weep and
laugh with those who laugh".
5. A community celebrates together.
It brings imagination, feelings and art to play in
the collective affirmation of persons and events
and mysteries of life.
6.
A healing community heals not only by the explicitly
therapeutic programmes but also by its process of
affirmation and the strength of the relationships.
Community is an antidote against alienation,
loneliness, insecurities and the resultant
psychosomatic problems.
7.
A liberating community, conse uently a healing
community is a participating community.
Participation in decision making is what makas a
mass into a people. When people decide together they
become conscious of their dignity as partners in
progress, as subjects and equals and not just
objects and the ruled.
8.
A community that is empowering, hence liberating
and healing, makes its members not only to decide
on the choice of various solutions proposed
but also to see the problems together.
Knowledge is power. A community that has been enabled
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3
to identify the problems and constantly to
evaluate them is an empowered community.
Fev; will dare to exploit that community.
9.
A community that is effective is necessarily small.
This follows from our earlier principles. A
big community can neither offer powerful relationships
nor scope for participation.
Only a fellow - ith a big voice can make himself
heard in a big village. Small men feel too small
to speak up in bigger structures.
10.
A community that intends to have wider macro
level ira-pact ensures linkage with other similar
communities through representative structures at
various levels. This ensures both the smallness
of the community and the wider level effective
action with effective grass-root participation.
11.
A healing community takes a holistic view of
health that includes the various social, economic,
environmental and other factors affecting health.
Do we have such communities?
Such structures or
infrastructures that would make community health action
more sustained and more participatory at grass-roots?
Until we have such communities whatever we call
community health programme may at the most be a rural
extension programme and not real community health action.
Community health is not just a programme for the
people; it is also something of the people and by the people.
4
4
They say examples speak louder. Let me share with you an
attempt where we try to integrate the community structure
aspect or the infrastructure aspect, into community health
action.
We call this project Basic Holistic Health Communities.
BASIC HOLISTIC HEALTH CONr.UHITIES
Our first step here is to start organising basic
communities of thirty houses each. We have altogether
170 such basic communities now.
These communities are geograohical, ensuring that
nobody is left out. This geographical aspect ensures also
a permanent identity for the communities. As long as
the houses are in a given geographical area the communities
are also there. Even if for some reason or other some communities
or all the communities in a village remain dormant for sometime
the day somebody wakes them up they come alive and ready
to jump into action.
These communities meet once a week or twice a week
or even oftener as the case may be. These meetings are
either for prayer, or for celebration, or for nonformal
education or for discussions on problems affecting them and
so on.
Five representatives from each community make the
representative general body of the villa< e. One representative
from each community makes the executive body of the village.
Representatives from the villages make the zonal
representative bodies, the general body having a representative
5
4
They say examples speak louder. Let me share with you an
attempt where we try to integrate the community structure
aspect or the infrastructure aspect, into community health
action.
We call this project Basic Holistic Health Communities.
BASIC HOLISTIC HEALTH COi-WHITIES
Our first step here is to start organising basic
communities of thirty houses each. We have altogether
170 such basic communities now.
These communities are geographical, ensuring that
nobody is left out. This geographical aspect ensures also
a permanent identity for the communities. As long as
the houses are in a given geograi hical area the communities
are also there. Even if for some reason or other some communities
or all the communities in a village remain dormant for sometime
the day somebody wakes them up they come alive and ready
to jump into action.
These communities meet once a week or twice a week
or even oftener as the case may be. These meetings are
either for prayer, or for celebration, or for nonfomial
education or for discussions on problems affecting them and
so on.
Five representatives from each community make the
representative general body of the villa- e. One representative
from each community makes the executive body of the village.
Representatives from the villages make the zonal
representative bodies, the general body having a representative
5
5
each from the communities and executive committee having
village representatives at the ratio of one representative
for five communities. What is discussed below that is
st grass root communities, each up to the top through
their representatives at various levels and what is
discussed at the top is reported back to the basic
communities.
Our system of handling finance in one of these villages
called Kodimunai, will make this accountability to the
grass roots clearer. Here the Treasurer is
free to spend on his own discretion upto Rs.50.00 for
emergency expenses. When the President and the Treasurer
decide together they can spend upto Rs. 10'.'. 00. The Executive
Committee of the village can spend upto Rs.500.00.
The
representative general body of the village having five
representatives each from the communities can spend upto
Rs.1000.00.
If it is more than Rs.1000.00 the representative
general body of the village makes the decision and sends
it for referendum among the basic communities. The decision
is not carried if more than half the number of the
communities fail to support the decision.
This type of two way communication helps for sustained
ection. It is enough for anybody in any of these 170
communities to remember the problem and the issue will come
alive again.
Once we build these basic communities we use these
communities for nonformal education on health concerns.
They become grass root forums for health motivation,
participation through decision-making evaluation and follow up
6
6
Here the care is taken not just to propose solutions
but more especially to make them see the problems themselves
so that through the process of ongoing situational
evaluation they are enabled to remain empowered.
This we do through various processes. One such
programme is our holistic health orientation camps in
basic communities. This willbe a week long programme where
trained volunteers help conduct health discussion
sessions in the basic communities with the help of a few
structured community-discussion exercises. Each community
will be encouraged to do also creative assimilation projrammess
whatever they learn in the discussions in an evening is
translated by the community into cultural programmes
to be staged in the community next evening. The village
level celebration that will take place the last day will
bring to a wider audience the best of the cultural programmes
produced by these communities. This health camp normally
will include also an exhibition and also half a day or one
day seminars to various categories of people with orwithout
audio visual programmes. Wherever possible we
would include
also house visiting programmes and a health survey of the
village.
In addition we. prepare discussion themes and circulate
them among the basic communities. These discussion themes
are structured in such a way that they elicit participation
of the community. Each theme contains an initial activity
related to the theme, questions to elicit participation,
a deepening process through the points given, questions
leading to community decision, and a conceding activity by
way of a song or so.
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7
Our next process will be to make these communities
accept responsibility for their own health care. This we
intend, to do by way of promoting a holistic health
insurance scheme run by the people- themselves.
Recently we had a survey to find out the average annual
medical expenses incurred by a family. This survey, conducted
in four villages, showed that the average amount was
Rs.4086.00.
We will be able to reduce this to just Rs.500.00
with proper
educational preparation and involvement
by the poo- le. For this, we would need to transcend the
allopathic boundaries and include other therapeutic
systems including drugless ones.
Our health insurance programme is expected to consist
of the following components: nonformal education through
basic communities, collection of funds through
basic communities, primary health care through village
level representative tody and its appointees, secondary
and other levels of health care throu *h zonal bodies and the
referral centres chosen by them.
Unfortunately, even the example given is not yet a
realised drearn. Well, this is the vision. We are not yet
sure how far we will reach. May be in spite of our
optimism we may r-'ach only half way. But we feel even
that would be worth the efforts, as it would be a se
step in the right direction.
PRIMARY FE'.LTH CARE
DECLARATION OF 'LEA-ATA — 12.9.1970
RELEVANT EXTRACTS.
Primary health care is essential health care based
or. practical, scientifically sound and socially acceptable
methods and technology made universally accessible to
individuals and families in the community through their full
participation and at a cost that the community and country
can afford to maintain at every stage of their development
in the spirit of self-reliance and self-determination. It
forms an
integral part both of the country’s health system
of which it is the central function and main focus, and of
the overall social and econcmic develo ment of the community.
It is the first level of contact of individuals, the family
and community with the national health system bringing health
care as close as possible to where people live and work, and
constitutes the first element of a continuing health care
process.
Primary health cares
1.
reflects and evolves from the economic •conditions
and socio-cultural and political characteristics
of the country and its communities and is based on
the application of the relevant results of social,
biomedical and health services research and public
health experience?
2.
addresses the main health problemsin she community,
providing promotive, preventive, curative and
rehabilitative services accordinglly;
2
2
3.
includes atleast: education concerning prevailing
health problems and the methods of preventing
and controlling them; promotion of food supply and proper
nutrition; an adequate supply of safe water and basic
sanitation; maternal and child health care, including
family planning; immunization against the major infectious
diseases; appropriate treatment of common diseases and
I/' '
/lip-. '-/I:.. .;..g injuries; prevention and
control of locally endemic diseases; and provision of
essential drugs;
4.
involves, in addition to the health sector, all related
sectors and aspects of natJonal and community development,
in particular agriculture, animal, husbandry, food,
industry, education, housing, public works, communications
and other sectors; and demands the coordinated efforts
of all those sectors.
5.
r-quires and promotes maximum community and
individual self-reliance and participation in the
planning, organization, operation and control of primary
health care, making fullest use of local,national and other
available resources; and to this end develops through
appropriate
education the ability of communities to
participate;
6.
should be sustained by integrated,functional and mutually
supportive referral systems, leading to the progressive
improvement of comprehensive health care for all, and
giving priority to those most in need;
3
3
7.
relies at local and referral levels, on health vzorkers
including physicians, nurses, midwives, auxiliaries
and community workers as applicable, as well as traditional
practitioners as needed, suitably trained socially and
technically to work as a health team and to respond to the
expressed health needs of the community.
ASIAN COMMUNITY HEALTH ACTION NETWORK (ACHAN)
was formed in 1980 by a group of twenty people with substantial
experience in working in health care among the poor in Asia
and operates through its network of concerned individuals and
non-gonernmental organisations in fifteen Asian countries, most
of whom have been engaged in innonative primary care at the
community level
ACHAN
seeks to spread a philosophy of community eased health care
that envisages a process of self reliant human development for
the oppressed poor in Asian communities which will result in
genuine social change.
ACHAN
views health as the physical, mental, social, spiritual,
economic and political shoneness of the individual and the
community
ACHAN
believes that health problems and priorities should be viewed
in terms in which the community sees them and that the community
should be actively involved in planning, implementation,
monitoring and evaluation of health care programmes.
BASIC PRINCIPLES IN C^I’S COMMITMENT TO COMMUNITY HEALTH
1.
Community Health is am approach to health care services.
It takas into consideration a philosophy, attitude and
commitment of working with people to help them help
themselves.
It is not a project, department or funding
system.
2.
Community Health focusses on the promotion and maintenance
of health and giv^s priority or etmhasis to the health
team, primary health care and community needs,
3.
Community participation is an essential component of
Community Health.
This recognises the potential rolgfaf
others to help educate, organise, mobilise and support
community development activities where the people have a
say in and control over their own future.
Community
participation thus becomes involved in people’s democratic
rights and their contributions to the development of their
society and nation.
4.
In Community Health there is a redognition of a three tier
system of primary, secondary and tertiary care approach to
the needs of the community and the resources available.
Therefore this approach accepts the role afid potential
of the hospital as integral to the Community Health.
A
commitment to Community Health is not necessarily anti
hospital. Yet the hospital needs to be supportive of
Community Health and recognise and accept this wider concern
in health care services.
5.
In the provision of services in Community Health there is a
bias towards those who are oppressed, exploited, the poor and
the marginalised.
Thus priority would be given to rural
areas and urban slums.
Special groups for concern would be
women, tribals, dalits, small marginalised farmers and
landless labourers.
2
2
6.
The organisation of services under Community Health would
be appropriate, acceptable, easily available and affordable.
It would be cost effective and willing to use unskilled, semi
skilled adequately trained local health personnel.
7.
There is a place for voluntary agencies in Community Health.
8.
Community Health accepts that health cannot be improved by
health services alone; health and development need to be
interlinked and interdependent.
9.
There is a place for appreciating local customs, traditions,
beliefs and health care systems and relating health
services to tha culture and socio-economic situation of
people.
Appropriate indigenous medical practices and
trained practitioners, or traditional birth attendants
are encouraged in Community Health.
10,
In tha final analysis Community Health is not apolitical.
If it concerns the welfare of people and the provision of
adequate and appropriate health care then health becomes a
social justice issue.
It is concerned with structures and
systems of society that seem to benefit a few at the
expense of many.
STAGES IN COMMUNITY HEALTH SERVICES lEMDInu, TO MO*t
CvhApLG”TE
PRIMARY HEALTH CARE DEVELOPMENT ARE:
Stage 0: Community has to coma to the hospital resulting in
limited access to health care.
Stage 1: Mobile clinics which give episodic services unable to
deal with complications developing between the
intervals of care.
Stage 2: Public Health Services which attempt to achieve disease
control without necessarily depending on active
recepient community involvement.
Stage 3: Hospital-based., community-oriented, Primary Health
Care where all resources and health funcationaiies
are taken regularly and frequently from hospital
bases into communities requesting and cooperating
actively with this assistance.
StagQ 4: Community Based Primary Health Care (CBPHC) with
facilities and health personnel firmly established
in communities requesting them and actively cont
ributing to their implementation.
Tertiary hospitals
are then used only for referrals, training and
assistance as and when required.
Stage 5: Multi-sectoral, multi.disciplinary integration of many
different components in each community, leading to
improved health and economic development.
Stage 6: Education, organisation, mobilisation of resources
and active implementation of socio-economic development
of people for their own total health at the micro
project level.
Stage 7: political activity by communities at the macro
level to ensure primary health care with the quality
of wholeness in life for all.
(Source: Fiona Plus, A Bi-monthly bulletin on Primary Health
Care in Community Health, )
STAGES IN COMMUNITY HEALTH SERVICES lEADXhu TO MCRt
('vhApLfTt
PRIMARY HEALTH CARE DEVELOPMENT ARE:
Stage 0: Community has to corns to ths hospital resulting in
limited access to health care.
Stage 1: Mobile clinics which give episodic services unable to
deal with complications developing between the
intervals of care.
Stage 2: Public Health Services which attempt to achieve disease
control without necessarily depending on active
recepiant community involvement.
Stage 3: Hospital-based, community-oriented. Primary Health
Care where all resources and health funcationaiies
are taken regularly and frequently from hospital
bases into communities requesting and cooperating
actively with this assistance.
Stag§ 4: Community Based Primary Health Care (CBPHC) with
facilities and health personnel firmly established
in communities requesting them and actively cont
ributing to their implementation.
Tertiary hospitals
are then used only for referrals, training and
assistance as and when required.
Stage 5: Multi-sectoral, multi.disciplinary integration of many
different components in each community, leading to
improved health and economic developmemt.
Stage 6: Education, organisation, mobilisation of resources
and active implementation of socio-economic development
of people for their own total health at the micro
project level.
Stage 7: political activity by communities at the macro
level to ensure primary health care with the quality
of wholeness in life for all.
(Source: Fiona Plus, A Bi-monthly bulletin on Primary Health
Care in Community Health, )
CHAI’s Philosophy and Vision of its Community Health Programing
The Community Health Department of CHAI also felt the need for
a correct understanding of its role in the field of health.
All
the points mentioned above were the basis for its conclusions.
Accordingly we believe that:
1.
In a country like India, so vast and varied, where
80% of its population lives in the rural areas and
about 90% of the country’s health care system caters
to the need of the urban minority, a new orientation
and rethinking of the whole health care system is the
need of the hour.
2.
Health is the total well-being of individuals, fami
lies and communities as a whole and not merely the
absence of sickness.
The demands an environment in
which the basic needs are fulfilled, social well-being
is ensured and osychological as well as spiritual
needs are met.
Accordingly a new set of parancters
will have to be considered for measuring the health
of a community such as the people’s part in decision
making, absence of social evils in the community,
organising capacity of the people, the role women
and youth play in matters of health and development
etc., other than the traditional ones like infant
mortality rate, life expectancy etc.
3.
The present medical system with undue emphasis on
the curative aspect tends mainly to be a profit
oriented business, and it concentrates on ’selling
health’ to the people, and is hardly based on the
ceal needs of vast majority of the people in the
country.
The root causes of illness lie dago ub
in social evils and imbalances, to which the real
2
2
answer is a political end, understood as a process
through which people are made aware of the real
needs, rights and responsibilities, available
x
resources in and around them and get themselves
organised for appropriate actions.
Only through
this process can health become a reality to the
vast majority of the Indian Masses.
4.
The concept of Community Health here whould be
understood as a process of enabling people to
exercise collectively their responsibilities to
maintain their health and to demand health as
their right.
Thus it is- beyond mere distribution
of medicines, prevention of sickness and income
generating programmes.
EXPLORING JARGON
Ths World Health Organization has defined Health as a * state
of physical, mental and social uell being and not merely an
absence of diseases of infirmity
While this definition focusses on the health of individuals
it could as uell be a description of the ideal state for
families and communities,. Community Health uould therefore
mean ’a precess of improving the physical,, mental and social
uell being of the community and all its component members.
This interest in health action focussed on the community and
not only on tho individual is not nou.
from times immemorial
efforts have been mads by doctors and communities to evolve
health actions that are focussed on the environment ~ physical,
chemical, biological, social, mechanical, psychological, culture
ecological rather than on individual patients.
This increasing
knouledgs has over times evolved into various disciplines
and today though ue use these names synonymously they do have
their oun distinctive meanings and focus.
In a uay they also
represent the historical development of skills focussed on
community health
1. Medicines The art of preventing and curing disease
2.
Hygiene: The Science of Health
3.
Public Health: The branch of medicine that deals uith
statistics, hygiene and the prevention and
overcoming of epidemics.
4.
Preventive Medicine: The branch of medical science that
deals uith prevention of diseases
5.
Social Medicine: Systematic study of human diseases uith
special reference to social factors
2
6.
Socialised Pledicine (^tate medicine):
Tha control of medical practice by an
organisation of the government, the practitioners
being an integral part of/the organisation from
which they draw their fees and to whibh the
public contribute in some form or other
(same as National Health Service)
7.
Community Pledicine! A unified and balanced integration
of curative, preventive and promotional
health services focussed on the
community
As Parks textbook (standard reference in India) says
"Once looked upon as a healing art, medicine is looked
upon today as the sum total of all activities of a
given society that tend to promote, restore and
maintain ths health of the people.
Uhere such a
concept prevails, medicine includes more than a
physician’s action; it becomes community health"
Community Health as we understand it today includes all
the ideas and disciplines mentioned above and more.
As new
aporoaches evolve the definition bee mes more comprehensive
RECOW-'CEWOATICNS
Ue therefore make tha following recommendations:
1.
The Government of India should, in consultation with
all concerned, formulate a comprehensive national
policy on health dealing with all its dimensions,
viz., ohilosophical and cultural, socio-economic,
nutritional, environmental, educational, preventive
and curative.
The coordinated and planned imple
mentation of this oolicy should ba the collaborative
and cooperative responsibility of individuals,
families, local communities, health personnel and
State and Central Governments.
2.
The basic objectives of this policy should be:
a.
to integrate the development of the health
system with the overall plans of sooio—economicpolitical transformation;
b.
to ensure that each individual has access to
adequate food and is provided with an environment
which is conducive to health and adequate
immunization, where necessary;
c.
to devise an educational programme which will
ensure that every individual has the essential
knowledge, skills and values which would enable
him to lead an effectively healthy life and to
participate meaningfully in understanding
and solving the health problems of the family
and the community;
d.
to replace the existing model of health care
services by an alternative new model which will be
- combining the best elements in the tradition
and culture of the peoplm with modern science
and technology,
2
2
— integrating promotive, preventive
and curative functions,
- democratic, decentralised and participatory,
— orianted to the people, i.e., providing
adequate health care to every individual and
taking spacial care of the vulnerable groups,
- economical, and
- firmly rooted in the community and aiming
at involving the people in the provision
of the services they need and increasing
their capacity to solve thein own problems,
and
s. to train the personnel, to produca drugs and
materials and to organise research needed for
this alternative health care system.
3.
A detailed time-bound programme should be prepared,
the needed administrative machinery created and
finance provided on a priority basis so that this
new policy will be fully implemented and the goal
of "Health for All" bo reached by the end of the
century.
(Recommendations of the ICMR/lCSSR on "Health for All"
An Alternative Strategy)
ORGANIZING PEOPLE FOR HEALTH
- ££221222_22^_£22^ ^ac*^2ii0^2•
Ansnt R S
(This reflection is based on the experience of work in a
health-education-concientization project in a few rather
remote, backward villages near Pune, and on the debates,
discussions in the Medico-Friend-Circle)
General Perspective on Health-work
Most of/the major determinants of the health status of a
population - food, water, sanitation, shelter, work-environment
cultural relations...... are far beyond the control of health
workers.
But Medicos can, with the help of the community,
organise preventive and therapeutic (symptomatic or curative)
services, can do health-education and advise the planners on
health-implications of different socio-economic interventions.
These medical interventions are very valuable to prevent
certain deaths and diseases, to relieve human su-ffering. But
they have only a marginal role in improving the overall
health-status of the population.
For example, infant and
child mortality can be reduced with immunizations and ORT...etc
but no health-programme has abolished malnourishment in
children
of a nation.
The department of health aiming to improve the health
of the people through so many national disease control programs
and now through the programme of ’Health for All by 2000 A.D’
is therefore a utopian, misleading idea.
As a part of a
thorough going socio-economic change, medical interventions
can be a very good supplementary tool to improve the overall
health-status of the people.
But the idea that "Health for
All by 2000 A.D" would be delivered by the health-ministry/
health projects by the NGOs, though very attractive, is a
2
2
misleading one.
All that health-people can hope to achieve is
"Health-care for All by 2000 A.D".
This is not sterile semantics.
There is a strong reason
and a contexi/’or making this distinction.
There is a wide
spread technocratic, and managerial illusion that improvement
in health of a nation, whidn is in reality, prrimarily a function
of socio-economic development, can be achieved with technolo
gical, managerial interventions.
Lay people are made to believe
that the beneficient state through its Health-Programmes, or the
Health-Projects run by NGOs, would improve the health of the
people with the help of modern science and technology.
These
slogans are being promoted in the context of the continuing
crisis in the economy leading to increase in poverty, unemploy
ment, inflation, drought and ecological disaster.
Other basic
element required by for the success of "Health for All" -
improvement in socio-economic situation of the people—is in
practice, missing due to this economic crisis.
What remains is
the misleading idea of "Health Eor All" to be achieved by the
efforts of the health-workers.
Those who undertake health-work primarily with an
intention of not ’giving a few pills’ but of doing some ’basic-
work’ can, in fact, make very valuable, basic work.
Many
improvements and some thoroughgoing changes are needed, many
new ideas, practices have to be founded and developed, many
vested interests to be fought in the field of organising
medical care and health-education.
technocratic work.
This is not a purely
There are many sociological, ideological,
technical, practical issues to be resolved.
Health-work, done
with the aim of taking up one of the so many challenging issues,
can be very valuable, basic work, a historical need today.
3
4
village Bommunity Development Association, on whose behest
this work is being done nor the local organisations are
health-organisations as sush.
Health work is considered as a
part of a broader work of education, conscientization,
organisation on a range of socio-economic issues.
Health is
considered neither the main issue nor a mere entry point.
Even with a limited aim, and with the support of the broader
social work done by the local organisation, the process of
increasing the health awareness amongst this marginalised
population and of fostering collective self-help has been
very gradual one and beset
with many problems.
Achievements, Problems, Contradictions
Our health-work consists of training of Village Health
Workers (chosen by the marginalised people themselves) in the
diagnosis and treatment of routine viral fevers, malaria,
diarrhoea, conjunctivitis, scabies, wounds, skin infections
etc., and distribution of iron and Vitamin-A supplements to
children and pregnant women.
These elementary curative
services are used to:
a.
establish the credibility of the Village Health Workers;
b.
as an occasion to interact with the people;
c.
an attempt to meet the felt-need of the people.
Rural peer are not much interested in general health-education;
given the arduous life they life.
But a rural poor is more
incluned to listen to why’s and how’s of diarrhoea-control,
when he/she is suffering from diarrhoea and effective treatment
is given by the same person who gives health-education about
diarrhoea.
Hence the strategy of coupling health-education
and therapeutics.
The result of this strategy is a mixed one.
Let me give
some examples of positive experiences and then of some problems
and difficulties:
5
Our VHUs have a much greater support from the community
than that the Government’s VHU has.
They are trained much
better because both the trainee and the trainer are really
interested in this work and its philosophy.
These UHUs
spend a lot t>f time for this work; attend frequent meetings,
participate in other programs of the organisation, travel
to and camo at other villages.
All this is possible because
of/a support from the community.
The honorarium of a mere
Rs.50/- per month does not explain the interest, efforts of
these VHUs.
(Many of the VHUs even do not get any monthly
honorarium).
The quack practice of some traditional therapi
sts and that of the compounder-turned-doctor, has been
considerably curtailed.
’injection-culture’.
Some dent has been made in the
People have collectively approached the
health authorities to complain about some specific grievances
about delivery of health services.
(for example, a Morcha
about a case of injection-pilsy; representations
about below
par functioning of health-services at the grassroot level..etc)
Slide-shows organised by VHUs on prevalent diseases like
scabies, diarrhoea are quickly being sought after.
More
than one hundred women from different villages had walked
for a feu kilometers and had waited patiently for hours to
see a slide show on women’s reproductive health.
This
indicates the interest of rural women in knowing about their
own body and health.
Discussions in meetirrs and Shibirs
about nutritional requirements of labourers, and of women,
about the relation between water supply and health has had
an impact.
In. the consciousness of a section of thr people
in the organisation, this new health-knowledge has given an
additional justification for the demand of higher minimum
wages, of leave from hard work during pregnancy, for improve
ment in water supply,
6
6
These developments are in a way collective attempts
towards control over health care activities; are rudementary
forms of organised efforts around health issues.
However,
along with such achievements, there are some knotty problems
which show that it is still a long way to go before the
awareness of the health problems increases to such an extant
that people start influencing the health services and policies
in accordance with their own needs.
a.
There is a tremendous gao between the consciousness
of health-workers and that of the people.
People are primarily
interested in medicines; rather than knowledge.
There is a
strong tendency of going to the commercial quack for an
injection, pay him five or ten rupees.
But when it comes to
paying ten paise for the tablet taken from the VHW, there is
a tendency bf not paying for this self-help, even though over •
a period ofytime, people have realised that these tablets are
a^feffective as these injections.
There is less of a tendency
to see that this process of self-help becomes self-reliant
the dominant tendency is either to seek a commercial treatment.
It is not easy to go beyond the stereotype responses conditio
ned by the dominant-culture.
b.
Hany people as yet
to see the work done by VHU8,
as a kind of social work done by the representatives of the
people.
Hany feel that these VH'Js work ’because they do not
need to work at home’ or ’because they must be getting
something from the agency’.
This is in spite of the fact
that these VH'Js were chosen by the people in a meeting; their
help and advice is sought; a call for a meeting, Shibir or
even for a Horcha is positively Responded to.
But still the
idea of a movement has not taken real roots.
c.
The Government health structure has cooperated by
providing medicines, sending their health personnel at request
7
7
etc.
In one remote area, a few of our illiterate VHMs usre
incorporated as Government's "Village Health Guides" (because
the PHC doctor was very much impressed by their knowledge),
even though the minimum educational qualification required
for this oost is 8th standard.
(This mutual cooperation
helps the health authorities to fulfill their targets for
remote areas)
But the Government authorities (all males)
dislike the questioning attitude, " rude manners" of our
women VHUs.
When our UHWs asked a pJHC doctor, in a meeting
about the budget of the PHC, and the expenditure under diff
erent heads, he got infuriated.
Relations were also strained
because a fflorcha was organised to demand justice in case of
an injection-palsy in a boy after an injection in his arm.
Any attempt to take democracy seriously, to know and to
question some of the practices in the PHE are frowned upon.
The 'beneficient authority' obliges by cooperating as long
as its hegemony is not threatned.
"People's participation"
is a nice slogan, but when it is taken seriously in a
critical fashion, such attempts are despised.
This in
turn dampens the already low initiative of the people for
asserting their own right.
Such
are the problems and contradictions in the process
of 'organising people for health care'.
Both from a
theoretical as well as practical view point, there is no
doubt, that without the collective participation, control by
the people in fulfilling their health care needs, the health
delivery system will not really serve the people,
But the
process is a very complex, slow and difficult one.
It is
easier to talk about nice things, but very difficult to achieve
them,
A lot of practical and analytical work has to be done
before ue can confidently talk about a strategy of "Health
Care by the people" or under the control of the people.
TRAIL'IKC FOR COn-lUNITY HEALTH CARE
Dara S Amar
(This jbaper highlights some of the attempts made in St John’s
Medical College, Bangalore, to orient Health Workers,
including Medical students, towards Community Health Care.
The attempts have provided invaluable insights into this
important goal.
Being a Medical College, St John’s aims
at providing the training component in the formation of
health teams)
The Salient features of our present programmes are s
1 * Health Team Training
St John’s Medical College is in a unique situation to train
various members of the health team under one roof.
We
are able to create a better understanding among the members
of the team of each other’s role.
Medical students. Nursing
students. Community Health Workers, Deacons, School teachers,
Village mothers etc.
are the various health team members
who get their training at the college.
While the ideal objective is health and development, by
virtue of the training and competence of the faculty, the
emphasis has been on training in health.
It is coinple-
mr-nted by traaining in development by other organisattions.
Community Participation
One of the main objective of the community health progra
mme of the college is the development of a participatory
process wherein the villagers themselves are responsible
for the financing of health care, supply of materials
and manpower.
This is particularly exemplified by the
Nallur Health Co-operative Centre, a project initiated
jointly by the college and the Mallur Milk Copperative
in 1973.
Village Health Committees have been formed at
each of the rural health centres and decisions are
....2
2
participatory in nature.
A large part of the organisation of
speciality rural camps are also done by the villagers.
This
is through their village youth groups and Mahila Mandals.
Even in the training of the health workers including medical
students, the village leaders are drawn in as resource
persons.
Coordination with other agencies
We work in coordination with governmental and non-governmental
health institutions.
Programmes such as the Rural Mobile
Clinics, Universal Immunization Programmes, integrated Child
Development Scheme, National Social Service and Rural
Internship Training are examples of such coordinated efforts.
Cur teaching faculty also act as guest faculty for various
sister institutions and organisations involved in health and
development.
Integrated health Care
Villagers in India often resort to indigenous systems of
medicine.
The training at the college of the health workers
including cur medical students, includes training in Herbal
Medicine, Herbo Mineral Medicine, Acupressure, Homeopathy
and Yoga.
Many of our graduate doctors working in remote
rural areas, have substantiated the fact that there is need
for integration with other systems of medicines as is being
attempted at the college.
Health Education - A priority
After years of experience in training health team members
for the villagers, we feel there is a greater need to pay
attention to training in health education.
In the long
run, it is the health education programme that have paid off
the maximum dividends.
With this in view, health education
receives a top priority in the traifting programmes conducted
3
4
senitize the health worker to the various aspects of rural
life and how each of these aspects is related to the total
health of the villagers.
Reaching out
Considering the resources and facilities available for
health care at St John's it is quite natural to try and reach
out to the underserved areas using the available resources
for health care.
Rural camps in the field of eye, ear, nose
and throat, skin, teeth, child health and General Surgery
are conducted in the villages.
Methodologies have been
evolved at the village 1*—el to ensure asepsis and follow-dp
for post operative care through the use of trained school
teachers, youth volunteers and traditional healers.
Specialist care, is thus made an ailable at the village itself.
In the bargain, the faculty have gained confidence that it
is possible to reach out with even ad anced health care to
the villages.
These exercises have also proved to be an
im ortant force of cohesion, among the various hospital
departments and Community Medicine Department.
The rural
mobile clinics further carry the health care facilities to
over
12 health centres, spread through three Community
Development Blocks covering over 300 villages.
In this
process of rendering services to the unreached, our trainees
(through the participation in such programmes) gain inva
luable experience^
Understanding health and disease holostically
In order that our health team trainees do not dichotomise
health care into various compartments, the training programmes
focus on families rather than individuals.
Through programmes
such as the Clinico-social case study and field family
health care projects, the trainees are n®’e to understand
the cause and consequence of disease in terms of multiple
factors rather than only the clinical signs and symptoms
of the disease affected ’erson.
Emphasis is laid on
5
5
the planning and management of health care at minimal cost.
Our graduates would also he cost conscious and make their
programmes financially self perpetuating in the village
communities rather than make the people dependent on
charities.
Serving the urban under-priviliged
Urban slums in and around Bangalore, are also served by the
Medical College.
Health programmes such as immunization
Coverage against the major killer dieseases for children,
maternal and child heal'-'' clinics for expectant mothers
and school health programmes, are some of the urban based
health activities.
In addition, the Medico-Social Unit aM
also aids in counselling for a&coholisrn, drug addiction,
juvenile deliquency etc.
Continuing education
Although basic training in health care is imparted to various
categories of health x^orkers, it is important a follow-up
is done on the utilisation of the knowledge gained at
St .John's.
For this purpose, several methods are followed.
At the professional level, doctors can seek elective posting
in selected specialities for further skill ehhancement.
Regional Colloquia are organised for sharing professional
experience among Community Health Workers and Rural doctors.
This provides an opportunity for learning from each other.
Continuing education is also provided by St John's for
health agencies from afar.
The United Planters Association
of Southern India (UPASI) works in collaboration with the
Department faculty to train their Medial Officers, Nurses,
Compounders and even their Estate Managers in the field
of health care and health management.
Periodical newsletters
6
also act as a means of networking for graduates and
Community Health Workers working in various parts of the
country.
Development as part of health
Extension training in agriculture, water resources and
veterinary care for village youth, are part of field training
orogrammes given in rural health centres.
The stress is
on youth motivation and training in these areas, especially
among the rural unemployed youth.
Functional literacy
programmes and vocational guidance are some of the other
services rendered in the villages.
Our health trainees,
including our medical students, participate in these de
velopmental programmes under their national Social Service
activities, which is coordinated by the department faculty.
Conclusion
All the programmes are updated constantly, depending on
the feed back received sfi their effectiveness and efficiency.
The emphasis is on training and health education rather than
mere provision of multiple services.
This ensures that
whatever have been the programme inputs, the results will
be long, lasting self perpetuating and effective.
TRAINING FOR COMMUNITY HEALTH CARE
Dara S Amar
(This paper highlights some of the attempts made in St John's
Medical College, Sangalore, to orient Health Workers,
including Medical students, towards Community Health Care.
The attempts have provided invaluable insights into this
important goal.
Being a Medical College, St John’s aims
at providing the training component in the formation of
health teams)
The Salient features of our present -programmes are :
1. Health_Team Training
St John's Medical College is in a unique situation to train
various members of the health team under one roof.
We
are able to create a better understanding among the members
of the team of each other's role.
Medical students, Nursing
students, Community Health Workers, Deacons, School teachers
Village mothers etc.
are the various health team members
who get their training at the college.
While the ideal objective is health and development, by
virtue of the training and competence of the faculty, the
emphasis has been on training in health.
It is comple
mented by traaining in development by other organisattions.
Community Participation
One of the main objective of the community health progra
mme of the college is the development of a participatory
process wherein the villagers themselves are responsible
for the financing of health care, supply of materials
and manpower.
This is particularly exemplified by the
Mallur Health Co-operative Centre, a project initiated
jointly by the college and the Mallur Milk Copperative
in 1973.
Village Health Committees have been formed at
each of the rural health centres and decisions are
....2
2
participatory in nature.
A large part of the organisation of
speciality rural camps are also done by the villagers.
This
is through their village youth groups and Mahila Mandals.
Even in the training of the heal th workers including medical
students, the village leaders are drawn in as resource
persons.
Coordination with other a22n£l££
We work in coordination with governmental and non-governmental
health institutions.
Programmes such as the Hural Mobile
Clinics, Universal Immunization Programmes, integrated Child
Development Scheme, National Social Service and Rural
Internship Training are examples of such coordinated efforts.
Our teaching faculty also act as guest faculty for various
sister institutions and organisations involved in health and
development.
Integrated Health Care
Villagers in India often resort to indigenous systems of
medicine.
The training at the college of the health workers
including our medical students, includes training in Herbal
Medicine, Herbo Mineral Medicine, Acupressure, Homeopathy
and Yoga.
Many of our graduate doctors working in remote
rural areas, have substantiated the fact that there is need
for integration with other systems of medicines as is being
attempted at the college.
Health Education - A priority
After years of experience in training health team members
for the villagers, we feel there is a greater need to pay
attention to training in health education.
In the long
run, it is the health education programme that have paid off
the maximum dividends.
With this in view, health education
receives a top priority in the trailing programmes conducted
3
3
at the college.
Innovative methodologies such as Child to
child health education, rural mothers motivation programmes
and rural school teachers health education training programmes
are some of the important programmes organised by the college.
The health education methodologies include the development
of local audio-vi.suala aids in the form of simplified demo
nstration models using locally available materials rather than
sophisticated charts, photos, films etc. The materials for
most health education sessions are prepared by the village
school children and village school teachers.
Nutrition
education involves teaching the village mothers to use their
own traditional recipes in a nutritionally correct manner.
The
aim here is to strengthen the existing traditional diets which
are often nutritionally far superior to the imported diet from
the urban areas,
Greater stress is laid on the use of local
cereals, pulses etc., along with promotion of breast feeding
as well as local weaning diets for the children.
Sensitisation to_the rural milieu
In order that all the trainees at St John's, including medical
students and nursing students, must understand the dynamics of
rural life, special training programmes are organised on a
residential basis at our rural health centres.
These rural
residential training programmes stress on understanding the
various factors which govern rural life and in turn the health
of the people.
Areas such as agriculture, animal husbandry,
small scale industry, customs and traditions, housing and
environment, role of women in society, food practices etc., are
all studied through field projects by the various groups of
trainees.
The training programmes are thus oriented to
4
senitize the health worker to the various aspects of rural
life and how each of these aspects is related to the total
health of the villagers.
Reaching out
Considering the resources and facilities available for
health care at St John's it is quite natural to try and reach
out to the underserved areas using the available resources
for health care.
Rural camps irs the field of eye, ear, nose
and throat, skin, teeth, child health and General Surgery
are conducted in the villages.
Methodologies have been
evolved at the village level to ensure asepsis and follow-dp
for post operative care through the use of trained school
teachers, youth volunteers and traditional healers.
Specialist care, is thus made aHailable at the village itself.
In the bargain, the faculty have gained confidence that it
is possible to reach out with even advanced health care to
the villages.
These exercises have also proved to be an
im ortant force of cohesion, among the various hospital
departments and Community Medicine Department.
The rural
mobile clinics further carry the health care facilities to
over
12 health centres, spread through three Community
Development Blocks covering over 300 villages.
In this
process of rendering services to the unreached, our trainees
(through the participation in such programmes) gain inva
luable experience^
Understanding health and disease holostically
In order that our health team trainees do not dichotomise
health care into various compartments, the training programmes
focus on families rather than individuals.
Through programmes
such as the Clinico-social case study and field family
health care projects, the trainees are made to understand
the cause and consequence of disease in terms of multiple
factors rather than only the clinical signs and symptoms
of the disease affected person.
Emphasis is laid on
5
5
the planning and management of health care at minimal cost.
Our graduates would also ' e cost conscious and make their
programmes financially self perpetuating in the village
communities rather than make the people depeddent on
charities.
Serving the urban under-priviliged
Urban slums in and around Bangalore„ are also served by the
Medical College.
Health programmes such as immunization
Coverage against the major killer dieseases for children,
maternal and child health clinics for expectant mothers
□nd school health programmes, are some of the urban based
health activities.
In addition, the Medico-Social Unit ati*
also aids in counselling for alcoholism, drug addiction,
juvenile deliquency etc.
Continuing education
Although basic training in health care is imparted to various
categories of health workers, it is important a follow-up
is done on the utilisation of the knowledge gained at
St John’s.
For this purpose, several methods are followed.
At the professional level, doctors can seek elective posting
in selected specialities for further skill ehhancement.
Regional CoDoquia are organised for sharing professional
experience among Community Health Workers and Rural doctors.
This provides an opportunity for learning from each other.
Continuing education is also provided by St John’s for
health agencies from afar.
The United Planters Association
of Southern India (UPASI) works in collaboration with the
Department faculty to train their Medial Officers, Nurses,
Compounders and even their Estate Managers in the field
of health care and health management.
Periodical newsletters
6
6
also act as a means of networking for graduates and
Community Health Workers working in various parts of t'ne
country.
Development as_part_of health
Extension training in agriculture, water resources and
veterinary care for village youth, are part of field training
programmes given in rural health centres.
The stress is
on youth motivation and training in these areas, especially
among the rural unemployed youth.
Functional literacy
programmes and vocational guidance are some of the other
services rendered in the villages.
Our health trainees,
including our medical students, participate in these de
velopmental programmes under their National Social service
activities, which is coordinated by the depatment faculty.
Conclusion
All the programmes are updated constantly, depending on
the feed back received eni their effectiveness and efficiency.
The emphasis is on training and health education rather than
mere provision of multiple services.
This ensures that
whatever have been the programme inputs, the results will
be long, lasting self perpetuating and effective.
COMMUNITY HEALTH AND PRIMARY HEALTH CARE
In 1978, Representatives of all the countries of the World
met in Alma Ata in USSR and committed themselves to the
concepts of ’Primary Health Care*
The Alma Ata declaration which is now a famous Health
document defined Primary Health Care
’as an essential health care made universally
accessible to individuals and acceptable
to them, through their full participation
and at a cost the community and country
can afford1
Primary Health Care (PHC) emerged in Alma Ata Declaration
as an alternative view of health and health care, which
included locating health in the wider context of socio
economic development and exploring actions beyond orthodox
medical care, that would be pre-requisites and/or supportive
of the health of communities.
The four principles stressed
in the Oeciaratinn were!
1.
Equitable distribution
2.
Community participation
3. Multisectoral approach
4,
Appropriate technology
Apart from a series of technological and managerial
innovations that were considered in the view of Health
action that emerged at Alma Ata, probably the most
significant development was the recognition of a ’Social
process’ dimension in Health care including
community
organisation, community participation, and a move towards
....2
2
equity.
Health service providers woult^be willing now to
aporeciate social stratification in society^ conflicts of
interests among different strata and to explore conflict
management.
These were not explicitly dslineatad but ware
inherent to the issues raised in the Declaration.
An
equally important fact was that these perspectives emerged
from the pioneering experience of a large number of voluntary
agencies and some health ministers committed to the deve
lopment of a more just anc/equitable health care
system.
Since India uas a signatory and evidently an enthusiastic
proponent of this idea it has now become fashionable in
India to use ’Primary Health Care’ to describe all Alternative
Health Action and synonymously with Community Health(CH)„ While
PHC and CH have a lot in common it is important to ramember
that they are not synonymous;, PHC is included in CH but CH
is a much more comprehensive term and idea.
What are these differences
1.
Primary Haalth Care concdntrates on Primary level (first
line contact) and ignores orientation of tertairy and
secondary care,
Community Health means a new approach at all three levels
2.
Primary Health Dars talks about a community in apolitical
terms as if they uere some homogenous group.
It ignores
caste/class and other dimensions in society.
Community Health recognises stratification and conflict
and the role this plays in accessibility and opportunity
in health.
3.
Primary Health Care leaves the ’development’ and modern
isation concept unquestioned.
Community Health locates itself in the centra of the
development debate and looks at health culture in a
uholistic uay.
3
3
4.
Primary Health Care leaves the medicalisatian of health
and the mystification and heirarchy of medicine unconfronted
Community Health confronts both these issues and tries
to evolve an alternative plural, demystification,
non-heirarchical value system.
5.
Primary Health Care has now become selectivised and all
these who would prefer vertical topdoun, siective, health
s
solution, funded by government and non-government,
international funding agencies have begun to gain control
over it.
Community Health by its very terminology does not allow
selectivisation, by concentrating on communities as
base, community as focus of action and participation,
the community health action remains comprehensive.
It may be diverse and if at all selective it is the
community which makes this choice.
CONNUNITY HEALTH AND HOSPITAL NEDICIN E
Ths community health approach has evolved from the
attempts of a large number of people concerned about the
present medicalised approach to health care and its
inadequacies in responding to the needs of the large majo
rity - the poor and marginalised groups in society.
Most
of the people involved in developing components of this
new approach have themselves had much of their training
and experience initially in the hospital-dispensary
oriented system.
Some of the approaches have emerged from
a confrontation of the existing value system and culture
of the western-technological model of health care of which
the hospital and dispensary are characterstic examples.
Does this mean that the ’community health approach’
and the existing medical system of hospitals, dispensaries,
health centres, doctors, nurses, drugs, technology, centres
of specialisation, education and research are incompatible?
While recognising the need for a ’paradigm’ shift in
attitude and approaches from the ’provision of medical care*
to the 'enabling of community health* we feel that these
are neither metually exclusive nor incompatible.
It is necessary to recognise that many aspects of the
value systems of existing hihgly technological western
models of care which we have inherited and continue to
transplant in our country are somewhat counter-productive
to the goals of community health.
It is necessary to recognise that by their very nature,
such highly capital intensive technology systems skew
health services in favour of those who can afford to pay
for them.
Gradually the forces of a market economy of which
....2
2
such a model is an integral part, alienates the structure
from the poor and underpriviliged and all those who basically
cannot afford the luxuries of the type of health such
systems symbolise.
However, since community health is basically a new
vision, a new value system and a new attitude it can
confront and pervade the entire existing superstructure
of health care.
Arising from community based experience as a new
vision, community health has to challenge the super
structure to become:
a.
more ’people* oriented
i.e sensitive to the realities of life of the large
■
•?
majority of people - the poor and underpriviliged,
b.
more ’community* oriented
i.e understanding health in its community sense and
not just as the problem of individuals.
c.
more socio-epidemioloqically oriented
understanding health in its wholistic sense - which
involves the biological, social, economic, cultural,
political and ecological dimensions.
d.
more democratic oriented
i.e more participatory and democratic in its growth,
planning and decision making process,
e.
more accountable
i.e increasing subservience of medicine, technology,
structures and professional actions to the needs and
hopes of the people, the patients, the consumers,
the ’beneficiafcies’ and the communities which they
seek to serve.
This confrontation of value systems and re-orientation
will help the superstructure and its different elements to
emerge from their present ivory-towered isolation and
3
3
irrelevance and gradually become supportive infrastructure
of a more just and healthy society.
However this change
cannot be miraculous or based on just good intentions
or any anount of wishful thinking.
It must be a serious
commitment to social analysis, participatory evaluation
and critical self-searching for greater relevance by
all those concerned with planning and decision making
in the present superstructure.
ISSUE RAISING - A CRITICAL TASK
When we think of ’Community Health’ or of health projects
of voluntary agencies, it is customary to think of micro level
field experiments and initiatives that have been described
previously.
However individually they can have little impact
on health policy or on the overall trends of health care
development in the country except at a local level perhaps.
No doubt a few individual ’charismatic' NGO health innovators
have participated and contributed to ’expert committee refle
ctions’ initiated by the government.
But on a more long term
basis and to counter ’entrenched' medical vested interests and
ra. attitudes there is a growing need for lobbying and
issue raising groups at national and regional levels.
This
calls for networking and dialogue around values and approaches
necessary for the emerging Community Health vision.
Are there such groups in the country.
In the 70s the
medico friend circle emerged as one such group out of the
ferment that marked the Indira/dP era leading to emergency
and its aftermath.
Over the years this group has brought
together people from diverse ideological backgrounds to discuss
issues relevant to health care and medical education in the
country and through its annual meetings and bulletin voiced
these concerns and- explored alternatives.
The Kerala Sashtra Sahitya Parishad is a different type
of issue raising group promoting a scientific attitude but
also questioning the role of science in society.
Though
regional in its focus KSSP has af late become an important and
crucial ’health issue' raising group in Kerala.
The people’s
science Movement in Maharashtra and more recently the Karnataka
Rajya Vignana Parishad have also begun to explore health issue.
Another important network on the national scene is the
All India Drug Action Network which has brought together a
»
2
2
wide variety of individuals, groups and associations into a
movement for a fcational drug policy and rational therapy.
AIDAN has not only worked on an alternative drug policy but
has also worked at various levels from parliamentarians to
the level of the people discussing issues and raising
consciousness about the various dimensions of the problem.
The ’Bhopal disaster’ was another major event leading
to a great deal of involvement and networking of groups in
the country supporting the ’plea for relevant research,
rehabilitation and legal compensation policies’ for the
affected victims.
In the eighties an increasing number of smaller groups
are emerging at the national, regional and local levels around
drug, health and other issues.
The ’mfc’ type of network is
now becoming a generic phenomena.
However, all these groups
put together are still making little impact on the health
situation and are still relatively marginalised.
Lobbying and issue raising is neither a popular task nor
an easy one.
The ’Drug activists’ and the ’Bhopal activists’
have experienced the non-re$)onsivaness of the established
status quo system to issues of justice on the ’Drugs’ and
’Bhopal’ matters.
A national Health action network is yet to emerge in
the country.
Even when it does it will take some time before
it can make an impact.
any longer.
This task can however not be ignored
THE MEOICO-FRIEND-CIRCLE —
Works towards a pattern of medical care adequately geared to
the predominant rural character of our country.
Works towards a medical curriculum and training tailored to the
needs of the vast majority of the people in our country.
Wants tovdpuslop methods ot medical intervention strictly
guided by the needs of our people and not by commercial interests.
Stands for popularisation and demystification of medical scienee.
Believes in a democratically functioning health team and
democratic dacnetralisation of responsibilities.
Stresses the primary role of preventive and social measures to
solve health problems on a social level and the importance of
planning these with active participation of the community.
Works to <-rds a kind of medical practice built upon human values,
concern for human needs, equality and against negative, unhealthy
cultural values and attitudes in society, e.g. glorification of
money and power, division of labour into manual and intellectual,
domination of men over women,
urban over ruaal, foreign over
Indian
Believes that non-allopathic therapies be encouraged to take thear
proper place in the modern system of medicd care —
—medico-fteind circle — perspective and activities. 1904
ALL INDIA DRUG ACTION NETWORK (AIDAN)
AIDAN consists of numerous health, consumer, legal aid and
human rights organisations and people’s science movements.
It is a gjjoing network of academicians, professionals,
social activists, individuals and organisations who are
deeply concerned about the drug issue and working towards
the adoption end implementation of a people-oriented
Rational Drug Policy in India as a part of a people's
Health Policy.
AIDANTS
Demands
* Availability of essential and life saving drugs
* Withdrawal of hazardous and irrational drugs
* Availability of unbiased drug information
* Adequate quality control and drug control
* Drug legislation reform
* Use of generic names
* Technological Self Reliance
9. Training 'enablers* not 'providers'
The Community Health Action initiators in the country
described earlier have also developed many training centres evol
ving middle level health manpower training programmes
in community health for doctors and nurses trained in
the orthodox medical system. Many of these training centres
have evolved in NGO projects after many years of primary
field level experience.
This new crop of training programmes differ from
conventional 'public health' and 'preventive and
social medicine’ in the country in many respects,
chief among which ares
1.
Most of the training programmes are open to
anyone interested in community health not
necessarily with a basic medical or nursing degree.
ii.
Nearly all of them have additional components in
the syllabus like social analysis, community dynamics
other systems of medicine, development issues,
appropriate technology, training of village based
health workers and so on which are not yet components
of public health courses in the country.
iii.
Nearly all of them are focussed on organisation
and practical management of community based
health programmes and training of local health
workers.
iv.
They all promote demystiffcation of medicine,
■SSUBMfr community participation, community
organisation and development. There difference
lies mainly in their overall socio-political
perspective and the role they expect of their trainee.
2
2
In this dimension they range from centres which
train for the delivery of an integrated package
of services to centres which train for enabling and
empowerment of communities.
v.
The duration of the course varies from 6 to 12 weeks
to 1 year.
vi.
Nearly all of them have experimented with more
participatory forms of training and generated
a number of case studies, role plays, simulation
games and learning exercises. This is in fact
a major contribution of these programmes though the
evolution of a participatory pedagogy is still
to be adequately recognised by orthodox medical
and health manpower educators in the country.
vii.
Apart from health projects which have grown into
training centres like RUHSA, CINI, Pachod, Jamkhed,
Deenabandhu, Ambilikkai, these training groups include
a medical college (St John’s, Bangalore), and a
Nurses Association (INSA, Bangalore) and two
Coordinating Agencies—CHAI & VHAI.
viii.
Only one academic department (Centre of Social
Medicine and Community Health, Jawaharlal Nehru
University, Nev; Delhi) offers MCH, MPhil and PhD
programmes in Community Health.
Only in 1988, has ti.ere been an attempt initiated by
VHAI, New Delhi, to organise a network of Community Health
Trainers in the country. It is hoped that this step will lead
to intensive dialogue and
mutual consultation among the
trainers so that some sort of common health manpower education
policy and new approaches to training can evolve which could
have wider relevance for manpower training in the country.
CHAI’s Philosophy and Vision of its Community Health Programme
The Community Health Department of CHAI also felt the need for
a correct understanding of its role in the field of health.
All
the points mentioned above were the basis for its conclusions.
Accordingly we believe that:
1.
In a country like India, so vast and varied, where
80% of its population lives in the rural areas and
about 90% of the country’s health care system caters
to the need of the urban minority, a new orientation
and rethinking of the whole health care system is the
need of the hour.
2.
Health is the total well-being of individuals, fami
lies and communities as a whole and not merely the
absence of sickness.
The demands an environment in
which the basic needs are f ulf illed, socbI well-being
is ensured and psychological as well as spiritual
needs are met.
Accordingly a new set of paraneters
will have to be considered for measuring the health
of a community such as the people’s part in decision
making, absence of social evils in the community,
organising capacity of the people, the role women
and youth play in matters of health and development
etc., other than the traditional ones like infant
mortality rate, life expectancy etc.
3.
The present medical system with undue emphasis on
the curative aspect tends mainly to be a profit
oriented business, and it concentrates on ’selling
health’ to the people, and is hardly based on the
ceal needs of vast majority of the people in the
country.
The root causes of illness lie deqa ub
in social evils and imbalances, to which the real
. ..2
z
X
C .
A?1/
2
answer is a political end, understood as a process
through which people are made aware of the real
needs, rights and responsibilities, available
resources in and around them and get themselves
organised for appropriate actions.
Only through
this process can health become a reality to the
vast majority of the Indian Masses.
4.
The concept of Community Health here whould be
understood as a process of enabling people to
exercise collectively their responsibilities to
maintain their health and to demand health as
their right.
Thus it is beyond mere distribution
of medicines, prevention of sickness and income
generating programmes.
M
BASIC PRINCIPLES IN CHAI'S COMMITMENT TO COMMUNITY HEALTH
n
1.
Community Health is am approach to health care services.
It takes into consideration a philosophy, attitude and
commitment of working with people to help them help
themselves.
It is not a project, department or funding
system.
2.
Community Health focusses on the promotion and maintenance
of health and gives priority or emohasis to the health
team, primary health care and community needs,
3.
Community participation is an essential component of
Community Health.
This recognises the potential rol^of
others to help educate, organise, mobilise and support
community development activities where the people have a
say in and control over their own future.
Community
participation thus becomes involved in people’s democratic
rights and their contributions to the development of their
society and nation.
4.
In Community Health there is a recognition of a three tier
system of primary, secondary and tertiary care approach to
the needs of the community and the resources available.
Therefore this approach accepts the role afld potential
of the hospital as integral to the Community Health.
A
commitment to Community Health is not necessarily anti
hospital. Yet the hospital needs to be supportive of
Community Health and recognise and accept this wider concern
in health care services.
5.
In the provision of services in Community Health there is a
bi-a-s towards those who are oppressed, exploited, the poor and
the marginalised.
Thus priority would be given to rural
areas and urban slums.
Special groups for concern would be
women, tribals, dalits, small marginalised farmers and
landless labourers.
2
2
6.
The organisation of services under Community Health would
be appropriate, acceptable, easily available and affordable.
It would be cost effective and willing to use unskilled, semi
skilled adequately trained local health personnel.
7.
There is a place for voluntary agencies in Community Health.
B. Community Health accepts that health cannot ba improved by
health services alone; health and development need to be
interlinked and interdependent.
9. There is a place for appreciating local customs, traditions,
beliefs and health care systems and relating health
services to the culture and socio-economic situation of
people.
Apprepriate indigenous medical practices and
trained practitioners, or traditional birth attendants
are encouraged in Community Health.
10. In the final analysis Community Health is not apolitical.
If it concerns the welfare of people and the provision of
adequate and appropriate health care then health becomes a
social justice issue.
It is concerned with structures and
systems of society that seem to benefit a few at the
expense of many.
(A Note to Health Action Team in Secudderabad)
Health Action
July 1989
Theme: Community Health in India
: A new vision of Health Care
1. This issue will consist of a longish Lead article put
together by the DHC team in Bangalore which explores various
aspects of Community Health in India including the following:
a.
Health Development In India
b.
faking Stock of this development
c.
Health scene in 80s
d.
Alternative Health project phenomena
e.
Recognising the emerging paradigm
f.
Community Health
i.
Vs PHC ii) Role of Hospitals ill) Movement dimension
g.
Community Health - Issue raising groups
h.
Community Health - Training initiatives
i.
Community Health - Research Centres
j.
Building the new Health paradigm
The article includes a series of box items or quotations from
the diverse materials that have emerged in this process.
Since the Lead article is a longish one it could be interspersed
by shorter contributions mentioned in (2)
2, In response to the Editor’s letter we received contributions
from seven resource people which have been edited for the issue
/
a.
Alok Mukhopadhyay - VHAI
b.
Fr Edwin - Kerala
c.
Dara Amar - St John’s
d.
Jacob Cherian - Ambilikkai
e.
Anant Phadke - mfc
two articles are in the post (telegram messages)
f.
Abhay Bang - SEARCH and g) S Joseph - MGDM Kangaiha.
2
(A Note to Health Action Team in Secudderabad)
Health Action
July 1989
Theme: Community Health in India
: A neu vision of Health Care
1. This issue will consist of a longish Lead article put
together by the OHC team in bangalore which explores various
aspects of Commuhity Health in India including the following:
a.
Health Development In India
b.
Taking Stock of this development
c.
Health scene in 80s
d.
Alternative Health project phenomena
e.
Recognising the emerging paradigm
f.
Community Health
i. Vs PHC ii) Role of Hospitals iii) Movement dimension
g.
Community Health - Issue raising groups
h.
Community Health ~ Training initiatives
i.
Community Health - Research Centres
j.
Building the new Health paradigm
The article includes a series of box items or quotations from
the diverse materials that have emerged in this process.
Since the Lead article is a longish one it could be interspersed
by shorter contributions mentioned in (2)
2. In response to the Editor’s letter we received contributions
from seven resource people which have been edited for the issue
a.
Alok Mukhopadhyay — VHAI
b.
Er Edwin - Kerala
c.
Dara Amar - St John’s
d.
Jacob Cherian - Ambilikkai
e.
Anant Phadke - mfc
Cwo articles are in the post (telegram messages)
f.
Abhay Bang - SEARCH and g) S Joseph - f*lGDI*l Kangaaha.
2
5b. Hou did thsss initiatives evolve
These initiatives evolved in a variety of uays.
Health uas some
times the entry point, sometimes it got into the package at a
later date.
Today they represent a uide variety of origins and
bases.
a.
A rural development programme uith a health component eg RfflHSA,
Tamilnadu, Banuasi Seva Ashram, UP
b.
A community based medical/health programme, eg Mini PHC of VHS,
Tamilnadu, RAHA Project, MP
c.
An integrated development programme in a tribal area. eg. VGKK,
Karnataka.
d.
An adult education/non-formal education programme uith a
e.
health component, dg AWARE, AP
A science education programme uith a health domponent
eg Kishore Bharati, MP
f.
A nutrition supplementation programme uith a health component.
eg Project Poshak</& Project Palghar , Maharashtra
g.
A conscientization/auareness building programme uith a health
h.
component, eg. Bodokhoni, Orissa
A community extension/outreach programme of a hospital
i.
A field practice area of a medical/nursinyparamedical training
j.
institute, eg. Mallur Health Cooperative, Bangalore
A school based health programme eg Deena ^eva Sangha, 8.lore
k.
A health programme as a component of a trade union movement
1.
A health programme as a component of a project focussed on
eg MGDM Hospital Project, Kangazha
eg. CMSS Health Project, '-'alii Rajhara
uomen’s issues eg. Women’s voice 8.lore, SEWA Ahmedabad
m.
Health as a component of a community action in urban slums
eg. Streehitakarini, Bambay
n.
A health programme for uorkers organised by an employers
association, eg GLUS, of UPASI for tea plantations, Kerala & TN
and so on
As the ’community health’ action initiatives greu in experience
and numbers a second generation of initiatives evolved:
a.
Issue raising groups like mfc, AIDAN, KSSP
b.
Coordinating/netuorking groups like VHAI, CHAI, CMAI and ACHAN
c, Community Health training centres like RUHSA, St Dohn’s and others
d. Community Health Research Centres like ARCH, FRCH, SEARCH & others
These uill be described later
2
Eamily Welfare activities
Environmental sanitation: Particularly safe drinking water supplies
and sanitary disposal of excreta, sullage and refuse
Nutritional supplementation and nutrition education, and
school health programmes
were the components
Rehabilitation as a health oriented action was seen mainly in the
context of people suffering from leprosy.
More recently the concept
of community based rehabilitation is also being experimented within
a few projects.
Basically this new approach believes in the
organisation of the disabled in the community into associations
and involving them in efforts to improve their own conditions
through programmes of education, income generation,skill training
and self reliance.
c•_Search_and_experimentation with low cost^ effective and
aporopriate technolor)j<
Hany projects had triedd to evolve
health care technologies,
or promote more appropriate
The emphasis was not only on it being
low cost but also on it being more culturally acceptable, demystif
ying and more within the operational capabilities of local people
and health workers.
These included
improved dai (1R8A) kits
nutrition mixes prepared from locally available foods
indigenous MCH calendar
locally manufactured lower limb prosthesis, b ngles and tapes
to measure nutritional status of children
low cost sanitation options
home based oral rehydration solutions
herbal and home remedies from the badkyard or kitchen.
Two additional areas of technological appropriatness which had
been experimented within many of these projects were:
i. Health communications - attempts had been made to
3
Ths Conmunit^ Health phenomena - Three questions
WHO were the community health project initiators?
I
Since ths late sixties and particularly in theseventies a
large number of initiatives and projects began to get established
outside the government system by individuals and groups kasn to
adapt health care approachas to the needs of our people.
Broadly classified as voluntary agencies in Health Care (now
also referred to as non-governmental organisations (NGOs) in
policy documents) these initiatives were predominantly rural
to begin with but later some of the focus also shifted to the
tribal regions and urban slums.
Starting with illness care most of them moved on to whole
range of activities and programmes in Health and Development
creatively rea-^feing to local needs and realities-.
<2—
The originators of these projects were doctors, nurses, health
and development activists, who had been challenged and stimulated
by the social disparities and health needs of thelarge majority
of people in the communities they served.
Each project or initiative evolved in the context of a local
social reality and a local health situation.
Since these were
diverse each of them evolved their own process of action,
package of services and local health organisation./
HOU did these initiiives evolve
These inititives evolved in a variety of ways.
Health was
sometimes the entry point, sometimes it got into the package
at a later date. "7<~cA
xeyo>-ez>e.znP <=,
cx-->cL
‘’c.-se-s,
a.
A rural development programme with a health component.
b.
A community based medical/health programme, e-^/
c.
An integrated development programme in a tribal area*? /&x tc,
<J
An adult education/non-formal education programme with
d.
'5 Rc>
P M-C c5[ V"H-
M-JIs
a health component,
b.
A science education programme with a health component, e^,
f. A nutrition supolementation programme with a' health
.
component,
g.
-
A-cV<S-c> Pcnha-k- -r- P^tsfe-aP Pe~} cA-~> a.
J
‘
A conscientization/awareness building programme with a
pocsziokhesv. ■., C-
health component,
h.
v
A community extension/outreach programme
of” a hospital e--=j- H&DM
I'<=-1 Pcje.c'pl'(d.'‘<p7''C-
i.
A field practice area of a medical/nursing/paramedical
I4ec}ll> Ctxrpe^^^vC . PP-^’d pdp*<5-
= <-
training institution. ‘-'5'
'
'
j.
A school based health programme, <s-^
k.
A health programme as a component of a trade union movement.<z--<=r
pw-j
/Pejlr P-pf
A health programme as a component of a project focussed on
1.
,
.
women’s issues
/=l
Vanuz-
e-
j
--
5ecJa,AA^Ixct
d
Health as a component of a community action in urban slums.
, P> crrnto’pj .
n. A health programme for workers organised by an employers
.
. .
e<s
Lc-huuv
association.
op
m.
and so on. .—
,
I.
)
As the ’community healttf action initiiives grew in experience
and numbers a second generation of initiatives evolved:
a.
Issue raising group
b.
Coordinating/netuorking groups
c. C o mm u n i t,y._.H e al_t h e d u c a_tio n/ d oc.ume n t/^re se ure e- c e n t r e s
Oji. Community Health training centres
J^,e. Community Health Research centees
Bu-t—mox-e—abaut i t later. •«
■TT-^-C
be <-U p<.v'U <>r.
ee«'!' “ere the comnonsnts of Health Action in these initiatives?
There has been a tendency in many circles to see each project
as an altarnative approach to health care.
Our experiences of
(6)
studying many of them convince us that many ideas, experiences,
A
components of service and the dynamics of action from these
projects taken together would help build an Alternative
Approach and none are independently the complete alternative.
Hence learning from the commonness of approaches and
identifying the rich variations that exist would be a more
meaningful way of deriving the new approach of community health
The component of the new approach to health action in the
Community are:
a.
Development activities
Recognising ill health as the product of poor nutrition, poor
income, poor housing and poor environment many health projects
had gradually?involved with
agricultural extension programmes
water supply and irrigation programmes
housing and sanitation schemes
income generation schemes
basic education including literacy, non-formal education
and adult education programmes .
^any projects which had started with a development focus were
in turn adding a health care dimension to their activities.
b. Preventive^ Promotive and Rehabilitative orientation to
ggglth action
dost of these health projects had moved beyond the medicalised
concepts of health symb lised by
drug distribution to
activities - focussed on individuals and groups that present
ill health and promote well being.
Immunization programmes
Maternal and child health care
....2
2
Family welfare activities
Environment al sanitation'Particularly safe drinking water
supplies and sanitary disposal of excreta, sullage and
ref use
Nutritional supplementation and/nutrition education
and
School health programmes
were the commonest compoaents.
Rehabilitation as a health-oriented action was seen mainly
in the context of people suffering from leprosy.
■'
c
■ • *.. ■ •;<
o-1 ip
c. Search and experimentation with low cost^ effective and
appropriate technology
Many projects had tried'' to evolve or promote more appropriate
health care technologies.
The emphasis was not only on it
being low cost but also on it being more culturally acceptable,
demystifying and more within the operational capabilities
of local people and health workers.
These included
improved dai (TBA) kits
nutrition mixes prepared from locally available foods
indigenous MCH calendar
locally manufactured lower limb prosthesis, bangles and
tapes to measure nutritional status of children
low cost sanitation options
homa based oral rehydration solutions
herbal and home remedies from the backyard or kitchen .
and -so^on.
Two additional areas of technological appropriatness which
had been experimented within many of these projects were:
i. Health communications - Attempts had been made to
....3
-
<£> h ■ f ><■■>
JJ f
j
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appropriate: technology
For PICH Work
1. Patient Retained Health Records
Coloured cards in a strong plastic cover retained with patients
who bring them during clinic visits.
Alloted spaces and
information for all aspects of mother and child care - Also
a personalised health teaching aid.
2.
Arm circumference insertion tape
To measure mid-upper aym circumference a useful indicator of
nutritional status of individuals and communities useful for
helping workers detect severe undernutrition and for raising
level of consciousness among community concerning the
problem.
3.
Child's bangle
Typically Indian method for diagnosing undernutrition by
mothers and health workers.
The bangle positive child includes
those with marasmic or third degree protein calorie malnutrition.
4.
indigenous Calendar
With festibals, full moons and conversion to English months
to help mothers place the birth of the child on the exact
date.
5.
Amsnisia recognition chart
Simple coral used to detect anaemia by comparing the colour
of tongue,lower lip and nails with picture on card the colour
of tongue.
6.
A Sterile delivery pack
Consisting of sterile cotton tie, a new blade and a small
bottle of disinfectant,this kit costing a few paises can
be used to prevent tetanus in the new born.
7.
Better Child Care
A * informative booklet with colourful pictures and
2
2
basic massages to help health workers and mothers to
discuss child care issues
—
vh-ai C?)
(FpX—Furjthar-details contac t VHAI9 Net/ Delhi)
"Technology can only be considered appropriate
if it helps lead to a change in the distribution
of wealth and power......’’
3
use low-cost madia alternatives like Flash cards and
flip charts and also to adapt local folk media and
traditional cultural/art forms like
puppetry
kathas (story telling)
street theatre
music and dance forms particularly those uhich
were common features of the festival culture in
India.
In tribal regions effective adoptions to ’nachna’
(song and dance improvisations) was a common feature.
Recording and evaluation tachniques - Many projects have
ii.
evolved simple mathods of recording quantifying and keeping
track of health activities or material resources utilised
by the health workers.
These were geared to the
capacities of local people (if they were people retained)
or to the capacities of the local health workers.
Many
were geared to get over the constraints of illiteracy.
d.
Recognition, promotion and utilization of local health
resources
Local health resources include local family based traditions
of health and self care as well as traditional systems of
medicine and their practitioners.
Many health projects had
created positive relationships with
local dais (traditional birth attendants)
traditional healers
folk medicine practitioners
and
the practitioners of various non-allopathic systems of
medicine practised locally.
This relationship had gone beyond a mere association to an
4
LOCAL HEALTH RESOURCES
’The Miraj Experience’
1. Training of Indigenous Dais
173 Dais out of 186 identified by a survey were trained.
The
emphasis of the training was on scientific techniques in home
delivery, elements of good antenatal, intranatal and post
natal care, basic cleanliness and hygiene.
They are also
taught to recognise danger signals in pregnancy/labour as
well as motivate for family planning methods.
Dais were
provided with autoclaved delivery kits.
2.
Village health aides
40 local part time women attendants provided to help the
government ANfl were retrained as village health guides who
could do early reporting of pregnant women and postnatal cases,
births and deaths, communicalbe diseases, fevers, neonates and
infants unprotected against preventable diseases, collect
mothers and children for immunization, distribute iror/and
folic acid tablets, follow up TB, Leprosy patients and so on.
3.
Indigenous medical practitioners
6 local Ayurvedic doctors were put in charge of Ayurvedic clines
run by the project.
Also serving the project area on a private
basis were 62 untrained practitioners of Ayurvedic medicine,
33 registered medical practitioners without formal training,
3 bone setters.
The doctors of/:he project would invite these
practitioners during their weekly village visit to join them
in examining and teeating patients.
This training method was
beneficial to both parties concerned.
Eric Ram (
)
4
acceptance of some of the medical and health practices of
these systems, by the projects themselves.
Promotion of
locally available herbal medicines and home remedies was
in important component in many.
e.
Training 2£_villat]e_based_health_cadres
Training of locally selected individuals in the village
in basic health care activities
minor ailment treatment
first aid
recognition of illnesses needing higher levels of
referral and care
nutrition
maternal and child health care
family welfare motivation
environmental sanitation
identification - reporting - basic measures in
communicable disease control especially
malaria
leprosy
tuberculosis
mental health care
and so on has been probably the most characterstic feature of
all these projects.
The selection methodology, the training
methodology, the range of skills and the scope of training,
the plan of activities and the remuneration and community
support of these health workers reflect// a wide diversity - but
the most import mt result of this trend has been the conscious
demystification of health issues and the creation of better
informed village-based individuals who are available to help
...5
•The Mandwa Experience’
Several Community Health Projects have demonstrated that most
communicable diseases can be controlled even under the existing
socio-economic conditions.
In the Mandwa Project thirty
village women given simple knowledge through weekly discuss
ions under the village tree, and with a simple supportive
service were able to achieve this.
few examples.
Let me illustrate with a
They took finger prick blood smears of any
patient suffering from fever with rigors and gave them four
tablets of chloroquine.
If the smear were positive they
gave Primoquine treatment.
flora than that they drew attention
of the village to control the mosquito vector.
They were
remarkably efficient in suspecting tuberculosis in individuals
with the classical symptoms especially if they were contacts
of known cases.
If the diagnosis was established on examination
of the sputum of X-ray they gave the 90 streptomycin injections
and supervised the regularity of the other anti tuberculosis
treatment by convincing the patient of its importance not only
for himself but also for the rest of his family.
taught
They also
other pimple measures like disposal of sputum to prevent
the spread of the disease.
These women diagnosed twice as many leprosy patients as the
full-time leprosy technicians, ensured that regular treatment
with Dapsone was taken after confirmation of diagnosis and
since these were in the early st ges, there was not a single
new case of deformity; the old deformed patients were helped to
return home and take regular treatment, for on having seen the
germs under a microscope they were able to convince the village
of chemical sterilization by regular treatment and induced
confidence by visiting the patients in their homes and par
taking of their meals.
2
There was a marked reduction in deaths from gastro-enteritis
not onl^ because of ORT but because of the creation of an
epidemiological conscioisiess in the villages for being prepared
for the monsoons.
The immunization rate for triple antigen rose from 15% to 92%
when the village health workers started giving them injections
on their daily rounds.
Since all pregnant owmen were identified
and immunized there was not a single death from tetanus in
five years.
No mass compaigns were even undertdcen in this
project, yet the so-called targets set by the PHC were over
reached even in family planning.
This people-based approach even succeeded in the detection
of cancer, mental illness and in rehabilitation of the dis
abled, all without campaigns and camps and at a fraction of
the normal cost of our health services.
Let us not minimize the role of the profession and services
in such a participatory aporoach.
Their main function should
be of teaching and encouraging the people to look after
themselves to the extent possible and overcome the fears in
culcated through professional mystification.
Another important
role is to provide the necessary supportive service for those
few problems which require skills and facilities of a higher
level.
Their’s is not to appropriate the functions which
rightly belong to the people, for experience has shown that
they cannot undertake these functions themselves even at a
far greater cost.
The present approach has only led to
exploitation of the people’s health by the private sector and
lack of accountability of the public sector without much
impact on the health status as revealed by our statistics.
The supportive professionalised services have also to be of a
graded nature starting with the paramedical worker at the
3
3
subcentre to tha surgeon and physician at the Community
Health Centre.
The primary role of the Community Health
Centre should nevefcthless be of monitoring the people's
health with priority to the promotive and preventive
services.
The ICSSR/lCMR report has estimated that about
98% of all health and illness care can be undertaken
within a
1,00,000 population covered by the Community Health Centre
at a cost of about Rs. 30 per capita per annum leaving only
a marginal sector for tertiary hospital care.
Also that
this can be achieved only if the people have th§ finaicial
and administrative control over their health services with
guidance and support by the professionals.
I know that this is a radical departure from the existing
situation and may not be readily acceptable to those who
believe that all decisions on health must be left only to
the medical profession.
But four decades experience in an
independent India has clearly demonstrated that we have
not been able to achieve the desired result despite the
vast expansion of medical services in both the public as
well as the private sector.
Dr N H Antia
Source: Medical & Non-Medical Dimensions of Health, National
Academy of Medical Sciences Oration, April 4, 1987
Nej/ Delhi
To. vcPr -■■■'
!. j >
5
thair own people in times of crisis.
The pedagogical
approach in the training session will determine whether these
village workers will become ’Lackeys of the existing system’
or the ’liberators of their people’ as David Werner had
warned from his Mexican experience.
In many projects, however
we discovered that ones health workers had been helped to
understand the situation and plan and decide on local health
actions, certain lead rinip qualities did emerge and action
on issues wider than health was gpierated.
In a fishing
community women health workers had effectively organised
peoola to orotest against ths local bus system which refused to
allow women to carry their baskets of fish on thebus to the
local market,
In many plantations health workers called
link workers had emerged as local union leaders.
Such
situation aaere not at all unusual.
f.
Increasing community participation in health decision
making
In addition to training uillaga health workers many of these
prgects have attempted to involve the community or their
representatives in the planning and decision making process
through the organisation of local village informal leaders.
Hany had involved existing
youth groups
mahila mandals (women’s groups)
farmers associations
coqjaratives
and
teachers and religoli s leaders
This is a very important trend and a rather challenging approach
For community participation to be a genuine process of enabling
people to take responsibilities foj/:hsir own health services
two pre-requisite conditions are essentials
6
i.
Firstly ths involvement of all sections of ths community.
Il
in the strafied village set-up with certain caste and
class groups dominating decision making and exploiting
certain other groups,, purposeful involuoment of dis
advantaged and oppressed sections of the village often
mean even exclusive involvement,
ii. Secondly the health action initi tors must be willing to
learn from the people and their nun experience of local
culture and social reality.
This means a ’democratic
dialogue’ on equal terms arid involvement in all aspects
of decision making not just participation in programmes
organised by the health team.
These twc pre-requisite conditions have evolved to varying
degress in the different projects and hence the nature of
participation is variable.
The qualitative difference from the/above approach is only
of emphasis.
Many projects have themselves initiated or
catalysed the development of
youth clubs
mahila mandals
farmers associations
and various group activities recognising the need for local
organisations to participate in planning and sustaining health
actions,
This action has also emerged from the observation that even
the poor and marginalised are not themselves a cohesive group
of a*community' in the real sense.
They have internalised
various social, cultural, political, religious divisions that
divide society at large.
Hence building groups relationships
7
7
and group organisations around issues and common actions are
themselves pre-requisites for community health actions.
h. A quest for financial self-sufficiency and cpneration
of local resources
I
Many projects have concentrated on the dimension of financial
participation of the community as a dimension of community
participation.
These projects have therefore concentrated
on generating local finances through
insurance schemes
adding health functions to dairy and other cooperative
graded payment of services according to family income
festival collections
and so on.
Experience has, however, cautioned that an
exclusive pursuit of this objective can often result in the
exclusion of those sections of the community which need the
health services most, especially when the [jporchasing;
capacity of people is so skewed.
Many projects have however widened this approach of generating
local resources to means
local resources - material,
structural and human - that can be harnessed to support health
These have included
actions.
grains for nutritional programmes
accommodation for clinics and programmes
basic supportive services by volunteers,
grain banks, voluntary labour, building materials
ans so on.
i) Education for Health
•Health* education has been an important approach in most
projects moving beyond the ’conservative’ health education
approaches which usually includes information transfer on
available health services and do’s and dont’s for individual
....8
8
health.
The efforts have been demystifying and conscientizing,
helping groups to understand the broader issues in health cars
as part of a wider awareness building process.
These have
been specific components of health action^for have been intro
duced as components of existing adult education and non-formal
education programmes.
As people discover the cause of illn
esses that they commonly experiences, and identify their roots
within their own social situation, they are prepared
something.
to do
This has meant that thio approach has often served
as a starting point for individual or group education.
School
health programmes where teachers and high school students are
oriented to do something about their own health, that of their
own families and their community, share the same vision.
j • £22£2i2£»l£2il2£_22£_221iii£21„2££122
There are some projects where the health teams based on thar
own experience have begun to show a deeper understanding of
issues for conscientization and recognise the need to support
political action especially those of ’people movements’ and
mass organisations.
This support may be through the
organisation of health activities particularly for members of
such movements or the addition of health demands on the agenda
of people’s struggles.
In the South, especially the demand
for provisions of water supply has often become such a
rallying point.
k
A>yjC- Ze c>L ., ?ka_
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ft study croup of ths Indian Council of Medical Research and
the Indian Council of Social Sciences Research listed out
J4ecJ^
the achievements and failures of th» whole,strategy as
/\
f ollcws:
Achievements
Life expectancy doubled
Health care services expanded
Manpower training centres increased
r
Small pox was eradicated
Plague, Cholera and Malaria controlled
Maternal and Child Health and Immunization programmes
increased
Largest Family Planning programme in the world
Failures
Health not integrated with Development
Little dent on Malnutrition and Environmental Sanitation
Morbidity Patterns not materially changed
Health Education neglected
TS, Leprosy, Filaria yet to be controlled
Infant/Maternal mortality rates still very high
Population stabilization - a long way to go
i
'
Overall
i
1. The model of health care was outdated and counter
productive benefitting the rich and/jell to do
upper and middle classes
2.
Health was a low-priority national investment
u
.
■
QUANTITATIVE EXPANSION
By 1<£?2 when ue celebrated the Silver Jubilee of our
Independence ue had made rapid strides and a phenomenal
quantitative expansion of health care services.
(Insert charts 18, 21, 27, 28, 30 and 31 from
HEALTH ATLAS OF INDIA, 1986
0 HZ.
P‘
Central Bureau of Health Inteligancs
J0
Directorate Deneral of Health Services
Ministry of Health & Family Welfare
Government of India
Nirman Bhavan, Neu Delhi )
l^cxhle.
■
Co
nji/k
. .
( cm r i u I) r a
>0-7/’s/ <?
CRITICAL INTROSPECTION
In the seventies, ths Government of India set up an expert
group on Medical Education and Support Manpower to take
stock of the situation and suggest proposals for reforms.
This is what the expert committee had to say:
1. ”A universal and egalitarian programme of efficient and
effective health services cannot be developed against
the background of a socio-economic structure in which the
largest masses of people still live below the poverty
line.
So long as such stark poverty persists, the
creative energies of the people will not be fully released;
the State will never have adequate resources to finance
even minimum national programmes of education or health;
and benefits of even the meagre investments made in these
services will fail to reach the masses of the people.
There is, therefore, no alternative to making a direct,
sustained and vigorous attack on the problem of mass
poverty and for creation of a more egalitarian society.
A nationwide programme of health services should be developed
yt
side by side as it will support this major national endeavour
and ba supported by it in turn.
.
lie have adopted tacitly, and rather uncritically the model
of health services from the industrially advanced and
consumption-oriented societies of the west.
This has its
own inherent fallacies; health gets wrongly defined in
terms of consumption of specific goods and services; the
basic values in life which essentially determine its
quality get distorted; over-professionalization increases
costs and reduces the autonomy of the individual; and
2
2
ultimately there is an adverse effect even on the health and
happiness' of the people.
Those weaknesses of the system are
now being increasingly realized in thsUest and attempts are
afoot to remedy them.
Even if the system were faultless,
the huge cost of the model and its emphasis on over-profe
ssionalization is obviously unsuited to the socio-economic
conditions of a developing country like ours.
It is therelftre
a traqddy that we continue to persist with this model even
!
whan those us borrowed it from have begun to have serious
misgivings about its utility and ultimate viability.
It
is, therefore, desirable that we take a conscious and
deliberate decision to abandon this model and strive to
create instead a viable and economic alternative suited to
our own conditions, needs and aspirations.
The new model will
have to place a greater emphasis on human effort (for which
we have a large potential) rather than on monetary inputs
»
(for which we have severe constraints).
3.
In the existing system, the entire programme of health
services has been built up with the metropolitan and capital
citis as centres and it tries to spread itself out irythe
rural areas through ibtermediate institutions such as
Regional, district or Rural Hospitals and Primary Health
Centres and its sub-centres.
Very naturally, the quantum
of quality of the services in this model are at their best
in the Centre, gradually diminish in intensity as one moves
away from it, and admittedly fail at what is commonly des
cribed as the periphery.
Unfortunately, the ’periphery’
comprises about 80 percent of the people of India who should
really be thq^ocus of all the welfare and developmental
I
...3
3
effort cf the State.
It is, therefore, urgent that this
process is reversed and the programme of national health
services is built with the community itself as the central
focus.
This implies the creation of the
needed health
services within the community by utilising all local
resources available, and then to sunplement them through a
referral service which will gradually rise to the metropolitan
or capital cities for dealing with more and more complicated
•s)
cases®
: 4.'Throughout the last two hundred years, conflicts have arisen
in almost every important aspect of our life, between our
traditional patterns and ths corresponding systems of the
West to which we have been introduced.
In many of these
aspects, the conflicts are being resolved through the
evolution of a new national pattern suited to our own
genius and conditions.
In medicine and health services
unfortunately, these conflicts are yet largely unresolved
and the old and new continue to exist side by side, often
in functional dishormony.
fl sustained effort is, therefore
needed to resolve these conflicts and to evolve a national
system of medicine and health services, in keeping with
J}
our life systems, needs and aspirations;'
_____________________________________
________________________________ /^erv k
Many other expert committee reports and policy stntments
of the seventies began to make critical observations about
the inadequacies of the present health care model and
exhorted all concerned to search for more relevant alter
natives and approaches
A MULTITUDE OF
QUESTIONS
What da all these statistics and critical introspection mean
to ths rural people who have suffered neglect for years?
Have
the post-independence policies made an impact on their lives?
Professor Ashish Bose while reviewing the Family Welfare
programme' has this to say:
^There are questions the masses would like to ask.
* 'Jhy are doctors not available at tbs Primary
Health Centres and ANI*ls net available at the
sub-centres?
* Why are medicines not available to the poor?
* Why is there no follow-dip of acceptors of
sterilisation?
* Why are women brought to the PHCs for
laparoscopic operation?
* Why are the X-ray machines not working in
so many PHCs and hospitals?
* Why is there no facility for oxygen and
blood transfusion euon in upgraded PHCs?
* Why are Government doctors so indifferent
to rural patients?
* Why don’t the PHC building have proper water
and electricity facilities?
* Why are the naw sub-centres and residential
houses built for ANf,ls so sub-standard and
located in such forlorn places?
Why do
contractors get away with sub-standard
construction under the so called Foreign-Aided
Area Projects?
”10 this controversy, if there is a fair debate, the masses
7c. Community Health: Is a movement emerging?
A study of the dynamics of community based health
action and the evolving approaches from micro level experience
show that ’community health’ could, become a movement
linked to a wider development and social chance process
in the country. There are many positive trends which
support this possibility. However, there are many negative
trends as well which could become major obstacles
for a genuine health movement in the country.
The positive trends are—
i•
Policy reflections of the Government
Policy documents and expert committee reports have
been echoing new approaches. Many decision makers,
administrators and technocrats within the entrenched
medical system are aware of these new approaches.
ii.
"Villace Health Worker Army”
A growing army of villagers and lay people have been
trained as village health workers by
oth non-government
and government agencies. Whatever the quality of training
this process itself is a phenomenal process of
demystification of medicine.
iii.
Non-medical Health Activists
A growing number of lay people, social workers,
developmental activists, journalists, teachers,
college students, non-medical scientists, lawyers,
consumer groups and so on are recognising the varied
dimensions of health and are getting involved in health
care issues
1
iv.
Health in the education process
Health issues are increasingly becoming part of the
syllabi of formal, non-formal and adult education
programmes in the country. Schools are also
gradually becoming focus of health activity.
v.
Health on the agenda of science movements
Movements for the popularisation of scientific
attitudes like KSSP (Kerala), Lok Vidnyan Sanghatana
(LVS, Maharashtra) and Karnataka Rajya Vigyan Parishad
(KRVP, Karnataka) are gradually taking up more
health issues.
vi .
Health issues emerging in other movements
The environmental movement has grown in recent
years with a number of processes around forest
issues, environmental issues and social problems.
In all of them, the health and nutrition of the affected
people is a growing concern. The women’s movement
is beginning to recognise health issues important
to women, eg., family planning, contraceptives,
amniocentesis and so on.
The Trade Union movement has got interested
in the’drugs issue’ but that involvement in health
issues is still quite marginal with the e ception o
independent trade unions like CMSS Dall! Rajhara
(Chatisgarh Project).
vii.
Health orientation of Coordinating groups and issue
raising networks
Groups like VHAI, CHAI, CMAI, mfc, SHC, AIDAN are
slowly increasing their commitment to lobbying on
various health issues.
All these trends call for a guarded optimism since
a series of negative trends are also becoming
incr asingly stident. These are—
i.
Commercialisation of medicine
Medicalisation, over professionalization and a
consumerist orientation of medical and health care
is increasing in the country. Medicine is becoming
big busness. The mushrooming of capitation fee
medical colleges and high technology investigative
centres catering to those vine can pay are components
of this trend.
ii.
Mushroominc; of medicalised health projects
Health projec s are mushrooming all over the country
sup orted by a combination of social, economic and
political factors. Foreign funding agencies are
vying with each other to fund the alternative.
Industrial houses are investing in it for income tax
purposes^ religious and social organisations are getting
involved for prestige, power and increasing their
membership; professionals getting involved for status
reasons. Most of these projects are •medical* providing
packages of services with little or no understanding
of the values/vision of the health movement or a
social analysis.
iii.
Verticaliz.ation of health efforts
Selectivization and vertical top-down health
programmes sponsored by government and encouraged
by International Funding Agencies like WHO, USAID,
UNICEF divert scarce resources and confuse community
health action initiators as well as waste time and
effort
A1
iv.
Inadequate Networking
Health action initiators themselves are not adequately
networking or lobbying with decision makers or opinion
leaders. While there has been a rich experience
of micro level experimentation there is inadequate
pooling of ideas, training, policy evolving efforts
and research;so the
.entrenched medical establishment
goes unconfronted.
v.
Status-quo forces
The ability of the existing status quo forces dominated
by the haves to internalise and coopt many of the
ideas and approaches into the*health, policy rhetoric*
butdefeating the spirit of the new vision must not be
under-estimated. The increasing number of paradoxical
policies and programmes on the national scene are an
incr asing evidence of this cooption.
vi.
Cooption of Health
The misuse and coption of the ;.ord—health—itself :C
a new and disturbing trends. The Drug Industry, the
medical technology industry, the five star hospitals,
the medical professionals are all using the word heath
to describe their initiatives most of which is the
same old curative high technology, drug oriented package -
deals under the new label. Alternatively through high
pressure advertising^insurance programmes, screening
programmes and medical check ups to promote ’over investigatioi
in the name of health is another trend.
Will the negative trends prevail and grow and prevent the
evolution of a health movement only time will tell. There
is every Indication that this may be so.
THE PARADIGM SHIFT
Medics! Model to Social Model of Health
INDIVIDUAL
COLLECTIVE/COMNUNITY
PATIENT
&
POPULATION
PERSON
&
SOCIETY
ANTI DEATH
ANTI DISEASE
PRO LIFE
PRO LIVING
PHYSICAL/MENTAL
PREDOMINANTLY
PHYSICAL/MENTAL/SOCI AL/
CULTUP AL/POLITICAL/ECOWJL OGICAL
DOCTORS/!WRSES
MEDICAL AUXILIARIES
TEAM OF HEALTH WORKERS
DISEASE
PROCESSES
SOCIAL
PROCESSES
HOS PI 'I ALS/DISPENSARIES
D RU GS/TECHN 01 ,QGY
—PROVIDING SERVICES
INTRACELLULAR
RESEARCH
PATIENT AS BENEFICIARY,
HEALTH PROMOTING AND
COMMUNITY BUILDING CENTRES
AND PROCESSES—-ENABLING/EMPOWERING
THE PEOPLE
——SOCIETAL RESEARCH
PEOPLE AS PARTICIPANTS
CONSUMER
SINGLE FACTOR
MULTI FACTOR
RISK/IDENTIFYING
PROCES^ IDEi
EPIDEMIOLOGY
EPIDEMIOLOG'
PROFESSIONALISED
COMPARTMENTALISED
MYSTIFIED KNOWLEDGE
DEMYSTIFYING,
PERSON CENTRED
AUTONOMY CREATING
AWARENESS BUILDING
'...UEST FOP VACCINE
AGAINST DISEASE
'FYI KG
Ds £
QUEST FOR AWARENESS BUILDING
PROCESS TO IMMUNIZE AGAINST
UNHEALTHY SOCIAL PROCESSES
Community/Village Health
Workers
O
c
i?
J
Source: Community Health Cell
Reflections^-)
Source: Community Health Cell
Reflections (u')
FROM INTRACELLULAR TO SOCIETAL RESEARCH
The new approaches to Community Health evolving in the
country have shown that a very important but neglected area
is research into socio-reconomic-political-cultural Factors
that affect health and disease and determine the nature of
health care development as well as the response of the
people.
Radical research in India has been preoccupied as in
other parts of the world with intracellulay or molecular
biological roots of disease and much of the research efforts
sponsored by ICMR and other national and regional,government
and private research centres has been in this direction.
Most
of it has been imitative research, ’we too have done it in
India' sort of Focus and there is the continued myopic wxki
view that the future of health in the country will be
determined by the discovery of a few more vaccines and
maybe the odd drug or contracsptiva.
This technological
focus has blinded us to the fact that the world-over health
care action initiators are proving again and again that the
clue to health of the people is in greater societal problems
in the wider social reality and to study them in a socioeoidemiological context to determine bottlenecks and to
evolve creative innovations is the need of the hour.
Some
ICMR institutions like the National Institute of Nutrition
in Hyderabad, National Tuberculosis Institute in Bangalore
and the Vector Control Research Centre in Pondicherry have
treaded the path of societal research and made unique
contributions to Primary Health Care and Community Health
but these are the exceptions to the overriding ru1e.
Have the NGO Health action initiators fared better?
Is anyone interested in health related societal research
in the country?
The development of NGO health research units keeping
in tuns with and exploring in depth issues arising out of the
emerging Community Health movement are few but these are
atleast positive signs.
The Foundation for Research in Community Health (Bombay)
the Action Research in Community Health, Mangrol (Gujarat),
Society for Education Research and Training in Health,(SEARCH)
Gadchirole (Maharashtra), Community Health Cell (Bangalore)
are examples.
A feu of the larger NGO Health Projects like CHOP, Pachod,
(Maharashtra) SEWA-Rural (Gujarat), CINI (Calcutta), Oamkhed
(Maharashtra) and RUHSA (Tamilnadu) have also begun to take up
some key research issues but this whole interest ie still
in a nascent state.
The Social Medicine and Community Health Department at
JNU is the only other national centre which is undertaking
societal research relevant to Health Care and Health policy
issues.
The medico fridnd circle’s efforts in providing
counter research expertise in the Bhopal disaster and its
aftermath was also a beginning of this new trend.
Much needs to be done by both governmental and
non-governmental groups, if the emerging ’Community Health’
approach and movement has to be put on a sound researched
social and epidemiological basis.
But this needs people who
see Research as an important need.
It also needs innovativa
•researchers’ who will be willing to learn existing health
care research methodologies and then creatively adapt it
through interactive, participatory approaches to study the
dynamics of Community Health care and the evolving movement.
With the preoccupation with ’microscopic research* are
such ’baloonist researchers’ available for the task?
Uill the M©Qs work together to pur pressure on the
•established medical system’ to commit itself to -ar new
vision of Health Care?
(^14-
Uill the N5&s work together to put pressure on ’Health
Policy and decision makers' to move beyond policy statements
and get health oriented programmes and actions of the ground?
<_U- c^C-ke-n
> V-ij.V'O—
Uill the N-G9s work with the people and their organisations
to enable and empower them to get the means, structures,
opportunities, skills, knowledge and organisations that
make health possible?
All these are unanswered questions.
Micro level experi
ments have shown that a lot is possible, but macro level
change requires a collective understanding and a colle
ctive action that is still to emerge .or-our—indi-vi-dualistic,
divided,politically sterile national scene.
UILL COMMUNITY HEALTH HAVE A CHANCE?
The World Health Organization has defined Health as a 1 state
of physical, mental and social well being and not merely an
absence of diseases of infirmity
While this definition focusses on the health of individuals
it could as well be a description of the ideal state for
families and communities. Community Health would therefore
mean 1 a process of improving the physical, mental and social
well being of the community and all its component members.
This interest in health action focussed on the community and
not only on the individual is not now.
From times immemorial
efforts have bean made by doctors and communities to evolve
health actions that are focussed on the environment - physical,
chemical, biological, social, mechanical, psychological, culture,
ecological rather than on individual patients.
This increasing
knowledge has over times evolved into various disciplines
and today though we use these names synonymously they do have
their own distinctive meanings and focus.
In a way they also
represent the historical development of skills focussed on
community health
1.
Medicine: The art of preventing and curing disease
2.
Hygiene: The Science of Health
3.
Public Health: The branch of medicine that deals with
statistics, hygiene and the prevention and
overcoming of epidemics
4.
Preventive Medicine: The branch of medical science that
deals with prevention of diseases
5.
Social Medicine: Systematic study of human diseases with
special reference to social factors
....2
2
6.
Socialised Medicine (^tate medicine);
The control of medical practice by an
organisation of the government, the practitioners
being an integisL part of/the organisation from
which they draw their 'fees and to whibh the
public contribute in some form or other
(same as National Health Service)
7.
Community Medicine: A unified and balanced integration
of curative, preventive and promotional
health services focussed on the
communi ty
As Parks textbook (standard reference in India) says
"Once looked upon as a healing art, medicine is looked
upon today as the sum total of all activities of a
given society that tend to promote, restore and
maintain the health of the people.
Where such a
concept prevails, medicine includes more than a
physician’s action; it becomes community health"
Community Health as we understand it today includes all
the ideas and disciplines mentioned above and more.
As new
approaches evolve the definition becomes more comprehensive.
TRADITIONAL MEDICINE
Ficus Carica
Fig. Tree (Anjir)
Use
1.
Tooth ache
apply few drops of milky jtiiice of the
tree by breaking a small branch. This can
be repeated if pain persists
2.
Ring worm
rub the affected area with the milky juice
twice a day until ring worm disappears
3.
Warts
wash the feet well and dry. Place few drops
on the warts and repeat every night until
wart disappears.
4.
Diabetes
figs are considered to have antidiabetic
properties. Few drops of milky juice of
figs in water every morning reduces
the sugar in the blood.
Lilliacease - Aloe vera/lndian aloe (H-Ghikavar)
Use
1.
Psoriasis
split the leaves of an aloe vera plant,
apply the juice directly to psoriasis and
let the juice dry. In a week it should be
healed.
2.
Bald head
fresh juice is to be applied on the scalp.
3.
Constipation
juice is a drastic purgative. Use fresh
juice 1-2 tsf for adults.
2
2
4. Dandruff
apply fresh juice on the scalp for an hour
and then wash it off. Repeat this daily until
dandruff disappears.
5. Burns
it has been proven a good remedy for
burns, treating effectively even 3rd degree
burns.
6. Halwa can be made out of freshy part of the plant which
is a remedy for indigestion and peptic ulcers.
Boat lilly, Commelinacea
Rhoeo spalhacea - Boat Lilly
Use
1. Whooping cough
leaves and flowers are boiled to make a
hot decoction. An oz. of the liquid is given
3 times a day and whooping cough disappears.
2. Bacillary dysentery : boil the leaves for 10 minutes and use
the decoction 3-4 times a day.
Papiliomacea - Fabaceae, Pongam oil tree - Karanj
Use
1. Herpes & scabies
apply the oil extracted from the seed for
3-5 days
2. Rheumatism
The oil massage with Karanj oil is considered
beneficial to those suffering from rheumatism
3. Bronchitis
the powdered seed is used as an expectorant
in bronchitis
4. Leprosy
oil of the seed is used in leprosy by the
tribals.
..... 3
3
Graminae
Lemon Grass
Use
1. cold and cough
widely used in cold ari cough. Tea
is prepared from leaves
2. Fever
it is given as a diaphoretic in fever
also carminative
3. Diuretic
tea made from the leave is diuretic
Euphorbiaceae - Phylanthus Niruri
Seed underleaf - Egg woman
Use
1. Jaundice
whole plant is used as a remedy
for jaundice
2. Diabetes
the plant is considered to be useful in
iS? diabetes
3. Dysentry
infusion of the young c_h shoots are
often used for dysentry
4. Skin ailments
juice is taken from the plant and
rubbed for skin ailments
Reference: 1988 Table Calendar, Holy Family Hospital, New Delhi
‘CmRs I C
■ |4<?cx 0U
P II
RECOmENDflTIONS
Me therefore make the following recommendations:
1.
The Government of India should, in consultation with
all concerned, formulate a comprehensive national
policy on health dealing with all its dimensions,
viz., philosophical and cultural, socio-economic,
nutritional, environmental, educational, preventive
and curative.
The coordinated and planned imple
mentation of this policy should be the collaborative
and cooperative responsibility of individuals,
families, local communities, health personnel and
State and Central Governments.
2.
The basic objectives of this policy should be:
a.
to integrate the development of the health
system with the overall plans of socio-economicpolitical transformation;
b.
to ensure that each individual has access to
adequate food and is provided with an environment
which is conducive to health and adequate
immunization, where necessary;
c.
to devise an educational programme which will
ensure that every individual has the essential
knowledge, skills and values which would enable
him to lead an effectively healthy life and to
participate meaningfully in understanding
and solving the health problems of the family
and the community;
d.
to replace the existing model of health care
services by an alternative new model which will be
- combining the best elements in the tradition
and culture of the people with modern science
and technology,
... . 2
2
- integrating promotive, preventive
and curative functions,
- democratic, decentralised and participatory,
- oriented to the people, i.e., providing
adequate health care to every individual and
taking special care of the vulnerable groups,
- economical, and
- firmly rooted in the community and aiming
at involving the people in the provision
of the services they need and increasing
their capacity to solve thein own problems,
and
e.
to train the personnel, to produce drugs and
materials and to organise research needed for
this alternative health care system.
3. A detailed time-bound programme should be prepared,
the needed administrative machinery created and
finance provided cn a priority basis so that this
new policy will be fully implemented and the goal
of ’'Health for All” be reached by the end of the
century.
(Recommendations of the ICflR/lCSSR on "Health for All”
An Alternative Strategy)
PRIMARY HEALTH CARE
DECLARATION OF ALMA-ATA — 12.9.1978
RELEVANT EXTRACTS
Primary health care is essential health care based
on practical, scientifically sound and'socially acceptable
methods and technology made universally accessible to
individuals and families in the community through their full
participation and at a cost that the community and country
can afford to maintain at every stage of their development
in the spirit of self-reliance and self-determination. It
forms an
integral part both of the country’s health system
of which it is the central function and main focus, and of
the overall social and econcmic develo ment of the community.
It is .the first level of contact of individuals, the family
and community with the national health system bringing health
care as close as possible to where people live and work, and
constitutes the first element of a continuing health care
process.
Primary health care:
1. reflects and evolves from the economic ■conditions
and socio-cultural and political characteristics
of the country and its communities and is based on
the application of the relevant results of social,
biomedical and health services research and public
health experience;
2. addresses the main health problemsin the community,
providing promotive, preventive, curative and
rehabilitative services accordinglly;
2
2
3, includes atleast: education concerning prevailing
health problems and the methods of preventing
and controlling them; promotion of food supply and proper
nutrition; an adequate supply of safe water and basic
sanitation; maternal and child health care, including
family planning; immunization against the major infectious
diseases; appropriate treatment of common diseases and
injuries; prevention and
control of locally endemic diseases; and provision of
essential drugs;
a.
involves, in addition to the health sector, all related
sectors and aspects of nat'onal an-
community development,
in particular agriculture, animal husbandry, food,
industry, education, housing, public works, communications
and other sectors; and demands the coordinated efforts
of all those sectors, ,
5.
r quires and promotes maximum community and
individual self~reliar.ee and participation in the
planning, organization, operation and control of primary
health care, making fullest use of local,national and other
available resources; and to this end develops through
appropriate
education the ability of communities to
participate;
6. should be sustained by integrated,functional and mutually
supportive referral systems, leading to the progressive
improvement of comprehensive health care for all, and
giving priority to those most in need;
3
3
relies at local and referral levels, on health workers
7.
including physicians, nurses, midwives, auxiliaries
and community workers as applicable, as well as traditional
practitioners as needed, suitably trained socially and
technically to work as a health team and to respond to the
,
expressed health needs of the community.
STAGES IN COMMUNITY HEALTH SERVICES LEADING TO MORE COMPLETE
PRIMARY HEALTH CARE DEVELOPMENT ARE!
Stags 0: Community has to come to the hospital resulting in
limited access to health care.
Stage 1: Mobile clinics which give episodic services unable to
deal with copplications developing between the
intervals of care.
Stage 2: Public Health Services which attempt to achieve disease
control without necessarily depending on active
recepient community involvement.
Stage 3: Hospital-based, community-oriented, Primary Health
Care where all resources and health funcationaries
are taken regularly and frequently from hospital
bases into communities requesting and cooperating
actively with this assistance.
Stagg 4: Community Based Primary Health Care (CBPHC) with
facilities and health personnel firmly established
in communities requesting them and actively cont
ributing to their implementation.
Tertiary hospitals
are then used only for referrals, training and
assistance as and when required.
Stage 5: Multi-sectoral, multi.disciplinary integration of many
different comoonenhs in each community, leading to
improved health and economic developmemt.
Stage 6: Education, organisation, mobilisation of resources
and active implementation of socio-economic development
of people for their own total health at the micro
project level.
Stage 7: political activity by communities at the macro
level to ensure primary health care with the quality
of wholeness in life for all.
(Source! Fiona Plus, A Bi-monthly bulletin on Primary Health
Care in Community Health, )
ALT1A ATA - - Tsn Years After
A decade ago, on September 25, 1978, the Alma Ata
conference formulated at Primary Health Care (fJ-HjC) strategy
Some
to achieve "Health for All" (HFA) by the year 2000.
argue that there has been virtually no success and that we
should abandon the strategy.
Others maintain that consi
derable orogress has been made and that we only need to
redefine the objectives slightly in planning for the year 2000
In its first evaluation report, WHO claimed that some
progress has been made towards HFA 2000.
Paradoxically, it
is the developed countries that have banefitted most,
Deve
loping countries still have not achieved much success in
PHC coverage.
p-:
The obvious success stories, such as the
achievement of 50 percent coverage in child immunization
and the final eradication of small pox, cannot conceal the
wide gulf which still exists between the urban "haves" and
the rural "have-nots".
Nearly 65 percent of people in/lndia
are trapped in the vicious cycle of poverty, malnutrition
and infectious disease, which reduces their capacity to
work and limits their ability to plan for the future.
For
example, 100 to 200 out of every 1000 infants born alive
still die during their first year of life.
In spite of the dismal statistics, some progress has
been made in the decado since Alma Ata, including reductions
in the infant mortality rats, the crude birth rate and the
death rate, and an increase in life expectancy.
The concept
of the community health worker, who is selected by the local
community to serve the community, has had considerable
impact.
Medical education has been re-oriented toward social
goals, fehd the teaching of preventive and social
medicine has been upgraded.
There has been a signifciant
progress in re-orienting the PHO to maximize the use of
limited resources through better managemant.
....2
2
were established in upper caste villages and to large extent
the poor were excluded from the services provided by us.
It
took us two years before we realised the implications and
moved away.
At the beginning we spent many months explaining our objectives
to "leaders” in the community and asked them to select village
health workers.
We found that though our stated target group
was the landless poor, the majority of those sent to ys by the
communities were from the land-holding classes.
to remedy this situation,
It took time
Mobile clinics were held on a
scheduled basis and it was several years before we learned
enough to see only those patients who were feferred to us
by the VHW.
The village clinics, though used as an "entry
point", tended to slow the process of acceptance of the VHW
by the community and we stopped doing them entirely after four
years,
Village health committees were formed with much fanfare but
after some time became inoperative when the committee members
found that apart from "prestige”, there was no monetary
benefit to be had.
Some of the committees also used the
VHW to run errands, etc., and had to be cautioned.
Once the
VHWs established their credibility, we found that the commi
ttee was not really necessary.
We now operate on the basis
of trust between us and the VHW, and between her and the
community.
Of course, two independent control mechanisms
do exist in the programme, more to see the effectiveness of
the VHW than to "supervise".
Use of sophisticated drugs and diagnostic tests were a
legacy of our expensive medical education, and we inflicted
them on the community for a long time before really understanding
3
3
the peoole’s economicl deprivation.
The emphasis we nou
lay on herbal remedies is a response to this.
Ue hav® seen
the proven efficacy of several herbs commonly used at the
community level.
We started with a base hospital oroviding secondary care.
The hospital had a vary busy and often lucrative practice.
Ue found that ue tended to spend more time "curing" people
and slculy started de-emphasising this aspect.
The effec
tive service carried out by the VHUs also diminished the
number of people uho needed secondary care.
Ue now believe
that if enough preparation of the community is done, it
should be possible to start programmes without base clinics,,
which ere often a hindrance.
Ue also believe strongly that
existing government facilities should be used, and if theyr
are inadequate, people should be organised to demand better
services rather than duplicating services.
Ue started this as a total community programme, for the rich
and the poor alike, for the upper and the lower caste, for we
believed that ue had a duty to all.
During the initial stages,
we found that the services offered by us were being extensively
used by those uho "have" land, money, education and who are
often from the upper castes.
This resulted in one of our
primary objectives being fulfilled - to double income levels .
A mid—programme assessment revealed that though ue had largely
achieved this objective, it was at the cost of the poor, who
showed only marginal growth while the "haves" showed specta
cular growth.
initiated.
This was evident in a dairy programme we
This package programme involved bank loans for
cows and feeds, fodder development, milk co-operatives and
transport of milk to the dairy.
Not taken into consideration
was tha fact that the landless barijans were not used to cows
had bo place to grow green fodder, and if they had any iilk
4
>o
even the last drop to the dairyji while their children
were malncurishad.
The land-downing classes, on the other
hand, increased income levels significantly through the
dairy programme.
Also, we believed chat the transfer of
milk from inpoverished areas to the cities to be made into
cheese, chcclats and condensed milk was not socially just.
This and other lessons made us resolve to work only with
the target group i.e., the powerless; the landless and the
harijan. All programmes - health, agricultural, animal
husbandry, etc - were, offerad exclusively to' this group.
The VHWs too, served only them,
Thus our focus became defined
and we were able to serve the taget group better.
£2n™unii.X Participation
Expectations of community participation started coming into
vogue in the early 70s.
Me, too, started with a lot of
assumptions: that communities are homogenous and therefore
able to take collective decisions based on common good; that
communities consider health as a priority and that they will
identify and act upon their "felt needs"; that 25% contribution
by way of labout was participation; that food-for-work progr
ammes were community participation, etc.
Only later did we
realise that widespread acceptance of our project did not mean
community participation.
We had, in fact, imposed a programme
on the community and had clearly defined areas in which they
should participate, thus acting contrary to our aim of enabling
them to make decisions affecting their lives.
We believed that the "leaders" expressed the collective need
of the people and many of our earlier schemes were based on
this assumption.
After several years of our education by the
community, us were able to see thefolly of this and involve
the entire community and not just "leaders" at all levels of
5
5
programme implementation, right from identification of priorities
and planning to evaluation.
To claim that ue have been entirely
successful in this would be untenable, but serious efforts bave
been made over the years.
Since we were unable to make defined
parameters, evaluation of this aspect is difficult.
It is also
hard, because the programme as we said earlier, has evolved
through many stages and has undergone changes in its objectives.
Self-Suff iciency
As a corollary of community participation, self-sufficiency
has been a goal in itself as well as a process.
Several ways
of seeking this goal were experimented with, particularly with
regard to the support of UHUs.
One way was to provide services
to the rich to raise resources.
There was an inherent danger
in this, for ue spent far too much of our times serving the rich
and this was contrary to our ideology, too.
Another al ternative
was to ask the VHUs to charge for their services, even a very
small amount.
The question remained, however: why should the
already marginalised and oppressed people be made to pay for
their health services while a lot of resources all over the
country were being allocated to server the "haves” and the
urban elite?
We had this problem until we realised that "self-sufficiency”
referred to the project, while what we were aiming to build at
the community level was "self-reliance".
Ue were working
towards building community capability in health care and,
community capability in health care and, hence, self-reliance.
Using a community-based approach, (appngriate personnel and
technology) we learned that it is possible to make communities
self-reliant.
Source:CONTACT, A bimonthly publication of the Christian Medical
Commission, Switzerland) (No 82 December, 1984)
ft Report from DEENABANDHUjTamilnadu)
Community Health : Learning from our failures
(Dr Pram John and Dr Hari John, graduates of CMC Vellore
recount the lessons they learnt from their failures so that
others may benefit from their mistakes and perhaps not
repeat them, thus saving time and efforts)
COMMUNITY HEALTH : Community Health, as it is known today,
started in the early seventies.
International organisations
and resource agencies from the West latched on to this whew
concept and touted it as being a panacea for all ills in the
community.
In the early stages there was a tendency on
the part of practitioners as well as promoters, to give less
publicity to problems and failures and to uphold '’successes’1
This resulted in :
1. a number of well motivated people going into community
programmes without learning from the failures of others and
thus having to reinvent the wheel, thereby wasting a lot of
.time and money, and
2. community health being practised in a haphazard
and
”non-scientific" way.
In fairness we should mention here that there were very few
models to go by and learn from.
But the lack of basic know
ledge of social sciences was a great handicap and retarded
our progress; often a trial and error method had to be
adopted.
Apart from tine attitudinal problems botn out of
established values reinforced by sophisticated education,
we faced some early prlblems.,
We were well received by the better-off, and it was they who
offered houses in villages free of cost for establishing
clinics.
This fulfilled our requirement of "community
participation".
Only later we realised that all our clinics
2
ORGANIZING dEQPLE TOR HEALTH
— Problems and Contradictions.
Anant R S
(This reflection is oased on the experience of work in a
health-education-concientization project in a few rather
remote, backward villages near Pune, and on the debates,
discussions in the fledico-Friend-Circle)
General Perspective on Health-work
Most offthe major determinants of the health status of a
population - food, water, sanitation, shelter, work-environment,
cultural relations...... are far beyond the control of health
But Medicos can, with the help of the community,
workers.
organise preventive and therapeutic (symptomatic or curative)
\
'
'
.
■
■
.
■ ,
.s’
services, can do health-education and advise the planners on
health-implications of different socio-economic interventions.
These medical interventions are very valuable to orevent
certain deaths and diseases, to relieve human su-ffering. But
they have only a marginal role in improving the overall
health-status of the population.
For example, infant and
child mortality can be reduced with immunizations and ORT...etc.
but no health-programme has abolished malnourishment in
children
of a nation.
The department of health aiming to improve the health
of the people through so many national disease control programs
and now through the programme of ’Health for All by 2000 A.0’
is therefore a utopian, misleading idea.
As a part of a
thorough going socio-economic change, medial interventions
can be a very good supplementary tool to improve the overall
health-status of the people.
But the idea that "Health for
All by 2000 A.D" would be delivered by the health-ministry/
health projects by the NGOs, though very attractive, is a
2
8-'
2
misleading one.
All that health-people can hope to achieve is
"Health-care for All by 2000 A.0".
This is not sterile semantics.
There is a strong reason
and a context^or making this distinction.
There is a wide
spread technocratic, and managerial illusion that improvement
in health of a nation, uhidn is in reality, prrimarily a function
of socio-economic development, can be achieved with technolo
gical, managerial interventions.
Lay people are made to believe
that the beneficient state through its Health-Programmes, or the
Health-Projects run by NGOs, would improve the health of the
people with the help of modern science and technology.
These
slogans are being promoted in the context of the continuing
crisis in the economy leading to increase in poverty, unemploy
ment, inflation, drought and ecological disaster.
Other basic
element required by for the success of "Health for All" improvement in socio-economic situation of the people—is in
practice, missing due to this economic crisis.
Uhat remains is
the misleading idea of "Health for All" to be achieved by the
efforts of the health-workers.
Those who undertake health-work primarily with an
intention of not ’giving a few pills’ but of doing some ’basic-
work’ can, in fact, make very valuable, basic work.
Many
improvements and some thoroughgoing changes are needed, many
neu ideas, practices have to be founded and developed, many
vested interests to be fought in the field of organising
medical care and health-education.
technocratic work.
This is not a purely
There are many sociological, ideological,
technical, practical issues to be resolved.
Health-work, done
with the aim of taking up one of the so many challenging issues,
can be very valuable, basic work, a historical need today.
3
3
Sut in ths sxisting socio-economic frame work and its
crisis let there be no illusion of really improving the
overall health of the people through health work.
Health-work alone ?
Anybody, who has any idea of the situation at the
grass root level, would agree, that in the rural areas,
it is not possible to build an organisation of the common
people around health issues.
The problem of poverty and of
paucity of basic amenities is so overwhelming that tural poor
are not in a position to rally around exclusively for health.
Those, whose basic needs are met, can perhaps form an
organisation on issues like occupational health.
Recently
in Puna, a Citizens’ group has been formed to discuss and
work even on the issue of mental health.
In rural areas,
and in the unorganised sections in the cities, however,
things are quite different.
But at the same time, unless
poor people become aware of health issues and actively seek
influence medical service, these services would continue
to be cut off from the people, and would continue to serve
the interests of those who need these services.
In other
words "health-care for all" can not be realised in its true
spirit unless it is’Health by All’——unless the people them
selves actively participate in the decision making and
implementation.
Even if it is not possible to build an
aganisation of rural poor exclusively on health, health
should be one of the activities of a group trying to organise
the rural poor for
justice and for development.
It is with this perspective, that a health-education-cum
conscientization work is being done for the past seven years
in a rather remote, backward area near Pune.
Neither the
4
village Sommunity Development Association, on whose behest
this work is being done nor the local organisations are
health-organisations as sueh.
Health work is considered as a
part of a broader work of education, conscientization,
organisation on a range of socio-economic issues.
Health is
considered neither the main issue nor a mere entry point.
Even with a limited aim, and with the support of the broader
social work done by the local organisation, the process of
increasing the health awareness amongst this marginalised
population and of fostering collective self-help has been
very gradual one and beset
with many problems.
Achievements, Problems, Contradictions
Our health-work consists of training of Village Health
Workers (chosen by the marginalised people themselves) in the
diagnosis and treatment of routine viral fevers, malaria,
diarrhoea, conjunctivitis, scabies, wounds, skin infections
etc., and distribution of iron and Uitamin-A supplements to
children and pregnant women.
These elementary curative
services are used to:
a.
establish the credibility of the Village Health Workers;
b.
as an occasion to interact with the people;
c.
an attempt to meet the felt-need of ths people.
Rural peor are not much interested in general health-education;
given the arduous life they life.
But a rural poor is more
incluned to listen to why’s and how’s of diarrhoea-control,
when he/she is suffering from diarrhoea and effective treatment
is given by the same person who gives health-education about
diarrhoea.
Hence the strategy of coupling health-education
and therapeutics.
The result of this strategy is a mixed one.
Let me give
some examples of positive experiences and then of some problems
and difficulties:
s
5
Our VHUs have a much greater support from the community
than bhat the Government’s VHU has.
They are trained much
better because both the trainee and the trainer are really
intarested in this work and its philosophy.
These tyHUs
spend a lot t)f time For thia work; attend frequent meetings,
participate in other programs of the organisation, trai/el
to and camp at other villages.
All this is possible because
of/j support from the community.
The honorarium of a mere
Rs.50/- per month does not explain the interest, efforts of
these VHUs.
(flany of the UHWs evan do not get any monthly
honorarium).
The quack practice of some traditional therapi
sts and that of the comoounder-turned-doctor, has been
considerably curtailed.
’injection-culture’.
Some dent has oeen made in the
People have collectively approached the
health authorities to complain about some specific grievances
about delivery of health services.
(for example, a Morcha
about a case of injection-pilsy; representations
about below
par functioning of health-services at the grassroot level..etc)
Slide-shows organised by VHUs on prevalent diseases like
scabies, diarrhoea are quickly being sought after.
Flore
than one hundred women from different villages had walked
for a feu kilometers and had waited patiently for hours to
see a slide show on women’s reproductive health.
This
indicates the interest of rural women in knowing about their
own body and health.
Discussions in meeting and Shibirs
about nutritional requirements of labourers, and of women,
about the relation between water supply and health has had
an impact.
In the consciousness of a section of tha people
in the organisation, this new health-knowledge has given an
additional justification for the demand of higher minimum
wages, of leave from hard work during pregnancy, for improve
ment in water supply,
6
6
These developments are in a way collective attempts
towards control over health care activities} are rudementary
forms of organised efforts around health issues.
However,
along with such achievements, there are some knotty problems
which show that it is still a long way to go before the
awareness of the hsalth problems increases to such an extent
that people start influencing the health services and policies
in accordance with their own needs.
a.
There is a tremendous gap between the consciousness
of health-workers and that of the people.
People are primarily
interested in medicines; rather than knowledge.
There is a
strong tendency of going to the commercial quack for an
injection, pay him five or ten rupees.
But when it comes to
paying ten paise for the tablet taken from the VHW, there is
a tendency bf not paying for this self-help, even though over
a period ofytime, people have realised that these tablets are
agfeffactive as thase injections.
There is less of a tendency
to see that this orocess of self-help becomes self-reliant
tha dominant tendency is either to seek a commercial treatment.
It is not easy to go beyond the stereotype responses conditio
ned by the dominant-culture.
b.
Many people as yet
to see the work done by VHWS,
as a kind of social work done by the representatives of the
people.
Many feel that these VHlJs work ’because they do not
need to work at home’ or ’because they must be getting
something from the agency*.
This is in spite of the fact
that these VHWs were chosen by the people in a meating; their
help and advice is sought; 3 call for a meeting, Shibir or
aven for a Morcha is positively tesponded to.
But still the
idea of a movement has not taken real roots.
c. The Government health structure has cooperated by
providing medicines, sending their health personnel at request
7
7
etc.
In one remote area, a feo of our illiterate VHUs were
incorporated as Government's "Village Health Guides" (because
the PHC doctor was very much impressed by their knowledge),
even though the minimum educational qualification required
for this oast is 8th standard.
(This mutual cooperation
helps the health authorities to fulfill their targets for
remote areas)
But the Government authorities (all males)
dislike the questioning attitude, " rude manners" of our
women VHUs.
When our VHUs asked a |3HC doctor, in a meeting
about the budget of the PHC, and the expenditure under diff
erent heads, he got infuriated.
Relations were also strained
because a Florclia was organised to demand justice in case of
an injection-palsy in a boy after an injection in his arm.
Any attempt to take democracy seriously, to know and to
question some of the practices in the PHC are frowned upon.
The ’beneficient authority’ obliges by cooperating as long
as its hegemony is not threatned.
"People’s participation"
is a nice slogan, but when it is taken seriously in a
critical fashion, such attempts are despised.
This in
turn dempens the already low initiative of the people for
assessing their own right.
Such
are the problems and contradictions in the process
of ’organising people for health care’.
Both from a
theoretical as well as oractical view point, there is no
doubt, that without the collective participation, control by
the people in fulfilling their health care needs, the health
delivery system will not really serve the people,
But the
process is a very complex, slow and difficult one.
It is
easier to talk about nice things, but very difficult to achieve
them.
A lot of practical and analytical work has to be done
before we can confidently talk about a strategy of "Health
Care by the people" or under the control of the people
TRADITIONAL MEDICINE
Ficus Carica
Fig. Tree (Anjir)
Use
1.
Tooth ache
apply few drops of milky jtiiice of the
tree by breaking a small branch. This can
be repeated if pain persists
2.
Ring worm
rub the affected area with the milky jdice
twice a day until ring worm disappears
3.
Warts
wash the feet well and. dry. Place few drops
or? the warts and repeat every night until
wart disappears.
4.
Diabetes
figs are considered to have antidiabetic
properties. Few drops of milky juice of
figs in water every morning reduces
the sugar in the blood.
Lilliacease - Aloe vera/lndian aloe (H-Ghikavar)
Use
1.
Psoriasis
split the leaves of an aloe vera plant,
apply the juice directly to psoriasis and
let the juice dry. In a week it should be
healed.
2.
Bald head
fresh juice is to be applied on the scalp.
3.
Constipation
juice is a drastic purgative. Use fresh
juice 1-2 tsf for adults.
2
4. Dandruff
apply fresh juice on the scalp for an hour
and then wash it off. Repeat this daily until
dandruff disappears.
5. Burns
it has been proven a good remedy for
burns, treating effectively even 3rd degree
burns.
6. Halwa can be made out of freshy part of the plant which
is a remedy for indigestion and peptic ulcers.
Boat lilly, Commelinacea
Rhoeo spalhacea - Boat Lilly
Use
1. Whooping cough
leaves and flowers are boiled to make a
hot decoction. An oz. of the liquid is given
3 tiroes a day and whooping cough disappears.
2. Bacillary dysentery : boil the leaves for 10 minutes and use
the decoction 3-4 tiroes a day.
Papiliomacee - Fabaceae, Pongam oil tree - Karanj
9
Use
1. Herpes & scabies
apply the oil extracted from the seed for
3-5 days
2. Rheumatism
The oil massage with Karanj oil is considered
beneficial to those suffering from rheumatism
3. Bronchitis
the powdered seed is used as an expectorant
in bronchitis
4. Leprosy
oil of the seed is used in leprosy by the
tribals.
.... 3
3
Graminae
Lemon Grass
Use
1. cold and cough
widely used in cold ad cough. Tea
is prepared from leaves
2. Fever
it is given es a diaphoretic in fever
also carminative
3» Diuretic
tea made from the leave is diuretic
Euphorbiaceae - Phylanthus IJiruri
Seed underleaf - Egg woman
Use
1. Jaundice
whole plant is used as a remedy
for jaundice
2. Diabetes
the plant is considered to be useful in
W diabetes
3. Dysentry
infusion of the young
shoots are
often used for dysentry
4. Skin ailments
juice is taken from the plant and
rubbed for skin ailments
Reference: 1988 Table Calendar, Holy Family Hospital, Nev? Delhi
THE NATIONAL HEALTHSCENE
A CHALLENGE FOR COMMUNITY H AL TH
Tetanus
In 1981, nearly a quarter million infants died in the
first month of life. The estimated mortality rate from tetanus
is 13.3 per 1000 live births in the rural areas and 3.2 in the
urban areas.
Diphtheria
The reported incidence, which is an under estimate admittedly
is around an verage 25000 cases a year, over 1975-81.
Pertussis
Around 300,000 cases reported annually.
Poliomyelitis
Estimated number of cases ranged from 14-1,000 to 23'., 000 a year.
Annual incidence rate is around 1.5 to 1.8 per 1000 children
0-4 years.
Measles:
Estimated number of cases was 0,96 million in 1977.
The case fatality rate is 1—3 per cent.
Tuberculosis
There are about ten million patients in India, a quarter
of them infectious. Some 500,000 deaths occur annually from
tuberculosis, most of them in children below 15 years. The
of
incidence rate^infection is
0.8 percent in the 0-4 year
age group; 1.1 percent in the 5-9 age group; and two percent
in the 10-14 year age group.
Leprosy
It is estimated in 1981 that there are 3.919 million cases with a
prevalence rate of 5.72 for 1000 population. 20 to 25 percent of all <
cases occur in children nearly one fourth are infectious and another
15 to 20 percent suffer from disabilities. The load of lepro='-
2
in the eastern belt of India comprising Andhra Pradesh,
Tamil Nadu, Orissa and West Bengal with 53 percent of
the case load.
Typhoid
Some 300000 cases are reported annually, the majority
among school children. The number of unreported cases would
be large.
Diarrhoeal diseases
About 10 percent of total infant deaths are due to diarrhoea.
40% of deaths among children under 5 years are diarrhoea-related.
An estimated 1.5 million children under five years die of it.
Acute respiratory infections
Over 17 percent of infant deaths are on this account,
the proportion being next only to premature births. Upto 40 percent
of out door patients and upto 35 percent of indoor patient are
children below five years. The case fatality rate is 10-16
percent.
Malaria
A major problem of resurgence—man-made urban malaria.
Fileriasis
Hundren million people in India living in endemic regions
facing the threat.
Malnutrition
It is estimated that state of malnutrition ranges from 50%
to 65% among the under fives in various places. This is not
protein-calorie malnutrition but total calorie malnutrition
ie., starvation. Results in lowering of resistance to infection.
(poverty line - those who do not have the purchasing power to
provide themselves with 2220 K. cals per day).
3
r
3
India
LDCs
World
27.5
19
9
70
60
20
% new born weighing less than 2.5 kg
2.5 kg
% of anaemia among pregnant
women
Blindness attributable to Vitamin A Deficiency
occurs among 20-30,000 children in India.
Water sup ly and sanitation
Only 31% of the rural population has access to porta
potable 'water and 0.5% enjoys basic sanitation.
Rural
Urban
Protected -water supply
10%
82.5%
Sound excreta disposal
2%
34%
A REPORT FROM KERALA
BASIC HEALTH COMUHITIES
—Fr Edwin MJ*
V.'e read and hear- a lot about community health these
days. But strangely we find that the proponents often fail
to speak about the most im; ortant component of a community
health programme, ie», communities themselves.
It would seem obvious that we need to have communities
to have community health. But unfortunately this is not so.
Building communities is yet to become an integral
part of the mental concept of a good many of our community
health t;orkers.
What is a community?
Or: What are the characteristics
that make a mass of people into a community?
We need to have
consensus of what we mean by community when we speak of
community health. Some of the guiding principles of a
community are:
1.
A community is not a crowd.
It is not a transient aggregation of passersby.
Community has certain amount of permanency.
2.
A community presupposes commitment to one another.
And this commitment is actually the most identifying
factor.
3.
A community has a shared vision.
Consensus on objectives holds the community together.
In this sense a community "works together".
2
♦Director
Xavier Pastoral Centre
PB 17, Nagercoil 629001
2
4.
A community means its members feel with one another.
A community, devoid of feelings, is not yet a community.
It may be just a task force.
Community members "weep with those who weep and
laugh with those who laugh".
5,
A community celebrates together.
It brings imagination* feelings and art to play in
the collective affirmation of persons and events
and mysteries of life.6,
A healing community heals not only by the explicitly
therapeutic programmes but also by its process of
affirmation and the strength of the relationships.
Community is an antidote against alienation,
loneliness, insecurities and the resultant
psychosomatic problems.
7.
A liberating community, conse uently a healing
community is a participating community.
Participation in decision making is what makes a
mass into a people. When people decide together they
become conscious of their dignity as partners in
progress, as subjects and equals and not just
objects and the ruled.
8.
A community that is empowering, hence liberating
and healing, makes its members not only to decide
on the choice of various solutions proposed
but also to see the problems together.
Knowledge is power. A community that has been enabled
3
to identify the problems and constantly to
evaluate them is an empovzered community.
Q
•*
Few will dare to exploit that community.
9.
A community that is effective is necessarily small.
This follows from our earlier principles. A
big community can neither offer powerful relationships
nor scope for participation.
Only a fellow • ith a big voice can make himself
heard in a big village. Small men feel too small
to speak up in bigger structures.
10.
A community that Intends to have wider macro
level im-pact ensures linkage with other similar
communities through representative structures at
various levels. This ensures both the smallness
of the community and the wider level effective
action with effective grass-root participation.
11.
A healing community takes a holistic view of
health that includes the various social, economic,
environmental and other factors affecting health.
Do we have such communities?
Such structures or
infrastructures that would make community health action
more sustained and more participatory at grass-roots?
Until we have such communities whatever we call
community health programme may at the most be a rural
extension programme and not real community health action.
Community health is not just a programme for the
people; it is also something of the people and by the people.
4
4
They say examples speak louder. Let me share with you an
attempt where we try to integrate the community structure
aspect or the infrastructure aspect, into community health
actiono
We.call this project Basic Holistic Health Communities.
BASIC HOLISTIC HEALTH COlftWITIES
Our first step here is to start, organising basic
communities of thirty houses each. We have altogether
170 such basic communities now.
These communities are geogra; hical, ensuring that
nobody is left out. This geographical aspect ensures also
a permanent identity for the communities. As long as
the houses are in a given geographical area the communities
are also there. Even if for some reason or other some communities
or all the communities in a village remain dormant for sometime
the day somebody wakes them up they come alive and ready
to jump into action.
These communities meet once a week or twice a week
or even oftener as the case ma
be. These meetings are
either for prayer, or for celebration, or for nonformal
education or for discussions on problems affecting them and
so on.
Five representatives from each community make the
representative general body of the villa e. One representative
from each community makes the executive body of the village.
Representatives from the villages make the zonal
representative bodies, the general body having a representative
5
5
each from the communities and executive committee having
village representatives at the ratio of one representative
for five communities. What is discussed below that is
at grass root communities, each up to the top through
their representatives at various levels and what is
discussed at the top is reported back to the basic
communities.
Our system of handling finance in one of these villages
called Kodimunai, will make this accountability to the
grass roots clearer. Here the Treasurer is
free to spend on his own discretion upto Rs.50.00 for
emergency expenses. When the President and the Treasurer
decide together they can spend upto Rs.10G.00. The Executive
Committee of the village can spend upto Rs.500.00.
The
representative general body of the village having five
representatives each from the communities can spend upto
Rs.1000.00.
If it is more than Rs.1000.00 the representative
general body of the village makes the decision and sends
it for referendum among the basic communities. The decision
is not carried if more than half the number of the
communities fail to suprort the decision.
This type of two wa> communication helps for sustained
action. It is enough for anybo. y in. any of these 170
communities to remember the problem and the issue will come
alive again.
Once we build these basic communities we use these
communities for nonfonnal education on health concerns.
They become grass root forums for health motivation,
participation through decision-making evaluation and follow up
6
6
Here the care is taken not just to propose solutions
but more especially to make them see the problems themselves
so that through the process of ongoing situational
evaluation they are enabled to remain empowered.
This we do
hrough various processes. One such
programme is our holistic health orientation camps in
basic communities. This willbe a week long programme where
trained volunteers help conduct health discussion
sessions in the basic communities with the help of a few
structured community—discussion exercises. Each community
will be encouraged to do also creative assimilation pro>ramres:
whatever they learn in the discussions in an evening is
translated by the community into cultural programmes
to be staged in the community next evening. The village
level celebration that will take place the last day will
bring to a wider -udicnce the best of the cultural programmes
produced by these com unities. This health camp normally
will include also an exhibition and also half a day or one
day seminars to various categories of people with orwithout
audio visual programmes. Wherever possible we
would include
also house visiting programmes and a health survey of the
village.
In addition we prepare discussion themes and circulate
them among the basic communities. These discussion themes
are structured in such a way that they elicit participation
of the community. Each theme contains an initial activity
related to the theme, questions to elicit participation,
a deepening process through the points given, questions
leading to community decision, and a concihding activity by
way of a song or so.
....7
1
Our next process will be to make these communities
accept responsibility tor their own health care. This we
intend to do by way of promoting a holistic health
insurance scheme run by the people themselves.
Recently we had a survey to find out the average annual
medical expenses incurred by a family. This survey, conducted
in four villages, showed that the average amount was
Rs.4086.00.
We will be able to reduce this to just Rs.500.00
with proper
educational preparation and involvement
by the peo le. For this, we would need to transcend the
allopathic boundaries and include other therapeutic
systems including drugless ones.
Our health insurance programme is expected to consist
of the following components: nonformal education through
basic communities, collection of funds through
basic communities, primary health care through village
level representative body and its appointees, secondary
and other levels of health care through zonal bodies and the
referral centres chosen by them.
Unfortunately, even the example given is not yet a
realised dream. Well, this is the vision. We are not yet
sure how far we will reach. May be in spite of our
optimism we may reach only half way. But we feel even
that would be worth the efforts, as it would be a se
step in the right.direction.
A COMMUNITY HEALTH RESOURCE INVENTORY
£50 titles ££22_ths_£ndian experience)
The 70s and 80s have seen an ’explosion’ of ’Community Health’
materials on ths Indian scene, with the increasing wealth of
grass-roots field experience.
Most of these materials are
unfortunately still in English and inspite of the presence
of large networks of NGO health initiators these are still
not as widely known or as widely read as they should be,
A Community Health Call, tentative Bibliography has identi
fied over 150 such materials.
A shorter version with sources
is given here highlighting 50 of them.
Source
A-Indian Council of Medical Research, New Delhi
1.
Alternative Approaches to Health Care, 1976
2.
Evaluation of Primary Health Care Programmes,
3.
Appropriate Technology for Primary Health Care, 1981
1980
B-Ministry of Health and Family Welfare, New Delhi
4.
Health Services and Medical Education (Srivastave Report) 1975
5.
Manual for Community Health Worker, 1978
6.
Manual for Health Worker - Female Vol I&II, 1979
7.
Manual for Health Worker - Male
Vol I&II, 1979
B. Manual for Health Assistants (Male & Female) 1980
9.
10.
Primary Health Centre Training Guides I-IV 1980
Handbook for the delivery care to mothers and
children in a community Development Block (Oxford University
C-Medico Friend Circle
11.
Press) 1980
In Search of Diagnosis - Analysis of Present system
of Health Care
1977
12.
Health Care - Which way to go?
1982
13.
Health and Medicine - Under the Lens
1985
....2
2
3- Voluntary Health Association of India, Neu Delhi
14.
Teaching Village Health Workers - a guide to the
1978
process
15.
Manual for child Nutrition in Rural India
16.
Where there is not doctor (revised Indian edition) 1979
17.
The National Health Policy
18.
A Manual of Learning exorcises for use in health
1978
training programmes in India
19.
1983
Better Care Series (8 problems)
£- Indian Social Institute, Neu Delhi
20.
Moving Closer to rural poor
1979
21.
Health & Culture in a South Indian village
1979
22.
People’s Participation in Development -
Approaches to non formal education
23.
1980
Changing health beliefs and practices in rural
Tamilnadu
1981
24.
Learning from the rural poor - experience of MOTT
25.
Development uith people - experiments uith
participation and non formal education
26.
1982
1985
Social activists and people’s movements
1985
F- Lok gaksh, Neu Delhi
27.
Formulating an alternative rural health care
system for India
28.
Poverty class and Health culture in India
29.
Health and Family Planning services in India -
1982
an epidemiological, socio-cultural and political
perspective.
G~ Catholic Hospital Association of India, Secunderabad
30 Health and Pouer to people (medical service special
issue) 1986
31.
Taking sides - the choices before the health uorker 1986
32.
Trainers manual for training community level
uorkers
1987
3
H- Foundation for Research in Community Health, Bombay
33.
Community Haalth Projects in Maharashtra - an
evaluation report
34.
1981
Health Status of the Indian People
I- National Institute of Mental Health and Neurosciences, Bangalore
35.
Manual of Mental Health for Medical Officers
1985
36.
Manual of Mental Health for Multipurpose workers
1985
3- National Institute of Health & Family Welfare, New Delhi
37.
Evaluation of CHU Seheme - a collaborative study
38.
Management Training for Primary Health ^are.
K- Indian Council of Social Sciences Research, New Delhi
39.
An Alternate system of health care services in
India - some proposals
1977
L- Centre for Social Action, Bangalore
40.
Health Care in India
1983
41.
Rakku’s Story
1984
M- Institute of Education, Pune
42.
Health for All ~ an alternative strategy
(ICMR/ICSSR Study Group)
1981
N- Centre for Science and Environment, New Delhi
43.
The State of India’s Environment - the
second Citizens’ report
1984-85
0- Kerala Sashtra Sahitya Parishad, Tribandrum
44.
Science as Social Action
1984
P- Community Health Cell, Bangalore
45.
Community Health: The search for an alternative
process (Draft report)
1987
9- Ford Foundation, New Delhi
46.
Anubhav Series! Experiences in Community Health
(12 project reports available)
1987
R- Some Foreign Publications (with Indian case studies)
87. Health by the People (WHO, Geneva)
48.
Practising Health for All (Oxford University
Press)
1975
1983
49.
Intersectoral linkages and health Development
(WHO, Geneva)1984
50.
Disabled Village Children - A guide for community
health workers, rehabilitation workers and
families (Hesperian Foundation, U.S.A)
1987
TRAINING FOR CO:~<UNITY HEALTH CARE
Dara S Amar
(This jbaper highlights some of the attempts made in St John's
Medical College, Bangalore, to orient Health Workers,
including Medical students, towards Community Health Care.
The attempts have provided invaluable insights into this
important goal.
Being a Medical College, St John's aims
at providing the training component in the formation of
health teams)
The Salient features of our present programmes are s
1• Health Team Training
St John’s Medical College is in a unique situation to train
various members of the health team under one roof.
We
are able to create a better understanding among the members
of the team of each other's role.
Medical students. Nursing
students. Community Health Workers, Deacons, School teachers.
Village mothers etc.
are the various health team members
who get their training at the college.
While the ideal objective is health and development, by
virtue of the training and competence of the faculty, the
emphasis has been on training in health.
It is comple
mented by traaining in development by other organisattions.
Community Participation
One of the main objective of the community health progra
mme of the college is the development of a participator!'
process wherein the villagers themselves are responsible
for the financing of health care, supply of materials
and manpower.
This is particularly exemplified by the
Mallur Health Co-operative Centre, a project initiated
jointly by the college and the Mallur Milk Copperative
in 1973.
Village Health Committees have been formed at
each of the rural health centres and decisions are
.2
2
participatory in nature.
A large part of the organisation of
speciality rural camps are also done by the villagers.
This
is through their village youth groups and Mahila Mandals.
Even in the training of the health workers including medical
students, the village leaders are drawn in as resource
persons.
Coordination with other agencies
We work in coordination with governmental and non-governmental
health institutions.
Programmes such as the Rural Mobile
Clinics, Universal Immunization Programmes, integrated Child
Development Scheme, National Social Service and Rural
Internship Training are examples of such coordinated efforts.
Our teaching faculty also act as guest faculty for various
sister institutions and organisations involved in health and
development.
Integrated Health Care
Villagers in India often resort to indigenous systems of
medicine.
The training at the college of the health workers
including our medical students, includes training in Herbal
Medicine, Herbo Mineral Medicine, Acupressure, Homeopathy
and Yoga.
Many or our graduate doctors working in remote
rural areas, have substantiated the fact that there is need
for integration with other systems of medicines as is being
attempted at the college.
Health Education_- A priority
After years of experience in training health team members
for the villagers, we feel there is a greater need to pay
attention to training in health education.
In the long
run, it is the health education programme that have paid off
the maximum dividends.
With this in view, health education
receives a top priority in the trailhing programmes conducted
3
3
at the college.
Innovative methodologies such as Child to
child health education, rural mothers motivation programmes
and rural school teachers health education training programmes
are some of the important programmes organised by the college.
The health education methodologies include the development
of local audio-visual a aids in the form of simplified demo
nstration models using locally available materials rather than
sophisticated charts, photos, films etc. The materials for
most health education sessions are prepared by the village
school children end village school teachers.
Nutrition
education involves teaching the village mothers to use their
own traditional recipes in a nutritionally correct manner.
The
aim here is to strengthen the existing traditional diets which
are often nutritionally far superior to the imported diet from
the urban areas.
Greater stress is laid on the use of local
cereals, pulses etc., along with promotion of breast feeding
as well as local weaning diets for the children.
Sensitisation to the rural milieu.
In order that all the trainees at St John’s, including medical
students and nursing students, must understand the dynamics of
rural life, special training programmes are organised on a
residential basis at our rural health centres.
These rural
residential training programmes stress on understanding the
various factors which govern rural life and in turn the health
of the people.
Areas such as agriculture, animal husbandry,
small scale industry, customs and traditions, housing and
environment, role of women in society, food practices etc., are
all studied through field projects by the various groups of
trainees.
The training programmes are thus oriented to
4
4
senitize the health worker to the various aspects of rural
life and how each of these aspects is related to the total
health of the villagers.
Reachino out
Considering the resources and facilities available for
health care at St John’s it is quite natural to try and reach
out to the underserved areas using' the available resources
for health care.
Rural camps in the field of eye, ear, nose
and throat, skin, teeth, child health and General Surgery
are conducted in the villages.
Methodologies have been
evolved at the village level to ensure asepsis and follow-i&p
for post operative care through the use of trained school
teachers, youth volunteers and traditional healers.
Specialist care, is thus made atailable at the village itself.
In the bargain, the faculty have gained confidence that it
is possible to reach out with even advanced health care to
the villages.
These exercises have also proved, to be an
important force of cohesion, among the various hospital
departments and Community Medicine Department.
The rural
mobile clinics further carry the health care facilities to
over
12 health centres, spread through three Community
Development Blocks covering over 300 villages..
In this
process of rendering services to the unreached, our trainees
(through the participation in such programmes) gain inva
luable experience^
Understanding health and disease holostlcal1y
In order that our health team trainees do not dichotomise
health care into various compartments, the training programmes
focus on families rather than individuals.
Through programmes
such as the Clinico—social case study and field family
health care projects, the trainees are made to understand
the cause and consequence of disease in terms of multiple
factors rather than only the clinical signs and symptoms
of the disease affected person.
Emphasis is laid on
5
' 5
the planning and management of health care at minimal cost.
Our graduates would also be cost conscious and make their
programmes financially self perpetuating in the village
communities rather than make the people depeddent on
charities.
Serving the urban under-nriyiliged
Urban slums in and around Bangalore, are also served by the
Medical College.
Health programmes such as immunization
Coverage against the major killer dieseases for children,
maternal and child health clinics for expectant mothers
and school health programmes, are some of the urban based
health activities.
In addition, the Medico-Social Unit 9SB
also aids in counselling for alcoholism, drug addiction,
juvenile deliquency etc.
Continuing education
Although basic training in health care is imparted to various
categories of health workers, it is important a follow-up
is done on the utilisation of the knowledge gained at
St John's.
For this purpose, several methods are followed.
At the professional level, doctors can seek elective posting
in selected specialities for further skill ehhancement.
Regional Colloquia are organised for sharing professional
experience among Community Health Workers and Rural doctors.
This provides an opportunity for learning from each other.
Continuing education is also provided by St John’s for
health agencies from afar.
The United Planters Association
of Southern India (UPASI) works in collaboration with the
Department faculty to train their MedicsL Officers, Nurses,
Compounders and even their Estate Managers in the field
of health care and health management.
Periodical newsletters
6
6
also act as a means of networking for graduates and
Community Health Workers working in various parts of the
country.
Development as part of health
Extension training in agriculture, water resources and
veterinary care for village youth, are part of field training
programmes given in rural health centres.
The stress is
on youth motivation and training in these areas, especially
among the rural unemployed youth.
Functional literacy
programmes and vocational guidance are some of the o her
services rendered in the villages.
Our health trainees,
including our medical students, participate in these de
velopmental programmes under their National Social Service
activities, which is coordinated by the depEEtment faculty.
Conclusion
All the programmes are updated constantly, depending on
the feed back received of their effectiveness and efficiency.
The emphasis is on training and health education rather than
mere provision of multiple services.
This ensures that
whatever have been the programme inputs, the results will
belong, lasting self perpetuating and effective.
Will the NGOs work together to pur pressure on the
’established medical system’ to commit itself to a neu
vision of Health Care?
Will the NGOs work together to put pressure on ’Health
Policy and decision makers’ to move beyond policy statements
and get health oriented programmes and actions of the ground?
Will the NGOs work with the people and their organisations
to enable and empower them to get the means, structures,
opportunities, skills, knowledge and organisations that
make health possible?
All these are unanswered questions.
Micro level experi
ments have shown that a lot is possible, but macro level
change requires a collective understanding and a colle
ctive action that is still to errage on our individualistic,
divided,politically sterile national scene.
WILL COMMUNITY HEALTH HAVE A CHANCE?
A MULTITUDE OF QUESTIONS
What do all these statistics and critical introspection mean
to the rural people who have suffered neglect for years?
Save
the post—independence policies made an impact on their lives?
Professor Ashish Bose while reviewing the Family Welfare
programme has this to say!
"There are questions the masses would like to ask.
* Why are doctors not available at the Primary
Health Centres and ANMs not available at the
sub-centres?
* Why are medicines not available to the poor?
* Why is there no follow-dip of acceptors of
sterilisation?
* Why are women brought to the PHCs for
laparoscopic operation?
►
* Why are the X-ray machines not working in
so many PHCs and hospitals?
* Why is there no facility for oxygen and
blood transfusion even in upgraded PHCs?
* Why are Government doctors so indifferent
to rural patients?
* Why don’t the PHC building have proper water
and electricity facilities?
* Why are the new sub-centres and residential
houses built for AflMs so sub-standard and
located in such forlorn places?
* Why dOi. contractors get away with sub-standard
construction under the so called Foreign-Aided
Area Projects?
nIn this controversy, if there is a fair debate, the masses
....2
I
2
will win and the Government would lose.
The sad fact
is that the infrastructure remains unutilised because
it is by and large not operational."
"Let us turn to the personnel now.
The Block Radical Officers ask:
* Why is there no set policy for transfers
and promotions?
* Why only doctors who can wield political
influence manage good postings, while the
others ’rot’ in villages for years together?
The ANRs ask:
* Why is there no concern for their physical
security when they are asked to work and live
in remote villages?
* Why did the Government insist on getting free
land from the Panchayat which in effect meant
the worst possible location for their quarters,
mostly on the outskirts of villages?
The Village Health Guides (VHGs) ask:
* Why have they not been paid their paltry
honorarium of Rs. 50 per month even after the
Government issued orders not to discontinue the
scheme under which mostly male VHGs have been
recruited?
(It was decided that in future only female VHGs will be
recruited)
Again, if there is a fair debate between the health staff
and the high level administrators, the Health Staff will
win"
In the seventies, the Government of India set up an axpsrt
group on Medical Education and Support Manpower to taka
stock of the situation and suggest proposals for reforms.
This is what the expert committee had to say:
1.”A universal and egalitarian programme of efficient and
effective health services cannot be developed against
the background of a socio-economic structure in which the
largest masses of people still live below the poverty
line.
So long as such stark poverty persists, the
creative energies of the people will not be fully released;
the State will never have adequate resources to finance
even minimum national programmes of education or health;
and benefits of even the meagre investments made in these
services will fail to reach the masses of the people.
Thera is, therefore, no alternative to making a direct,
sustained and vigorous attack on the problem of mass
&
poverty and for creation ef a more egalitarian society.
A nationwide programme of health services should be developed
side by side as it will support this major national eudeavour
and be supported by it in turn.
li
2.
Me have adopted tacitly, and rather uncritically the model
of health services from the industrially advanced and
consumption-oriented societies of the west.
This has its
own inherent fallacies; health gets wrongly defined in
terms of consumption of specific goods and services; the
basic values in life which essentially determine its
quality get distorted; over-professionalization increases
costs and reduces the autonomy of the individual; and
2
2
ultimately there is an adverse effect even an the health and
happiness of the people.
These weaknesses of the system are
now being increasingly realized in theWest and attempts are
afoot to remedy them.
Even if the system were faultless,
the huge cost of the model and its emphasis on over-profe
ssionalization is obviously unsuited to the socio-economic
conditions of a developing country like ours.
It is therelfljre
a tragddy that we continue to persist with this model even
when those we borrowed it from have begun to have serious
misgivings about its utility and ultimate viability.
It
is, therefore, desirable that we take a conscious and
deliberate decision to abandon this model and strive to
create instead a viable and economic alternative suited to
our own conditions, needs and aspirations.
The new model will
have to place a greater emphasis on human effort (for which
we have a large potential) rather than on monetary inputs
(for which we have severe constraints).
■
v
3.
In the existing system, the entire programme of health
services has been built up with the metropolitan and capital
citis as centres and it tries to spread itself out ir/;he
rural areas through ibtermediata institutions such as
Regional, District or Rural Hospitals and Primary Health
Centres and its sub-centres.
Very naturally, the quantum
of quality of the services in this model are at their best
in the Centre, gradually diminish in intensity as one moves
away from it, and admittedly fail at what is commonly des
cribed as the periphery.
Unfortunately, the ’periphery’
comprises about 80 percent of the people of India who should
really be thg^ocus of all the welfare and developmental
3
3
effort of the State.
It is, therefore, urgent that this
process is reversed and the programme of national health
services is built with the community itself as the central
focus.
This implies the creation of the
needed health
services within the community by utilising all local
resources available, and then to supplement them through a
referral service which will gradually rise to the metropolitan
or capital cities for dealing with more and more complicated
V
cases.
u
4.Throughout the last two hundred years, conflicts have arisen
in almost every important aspect of our life, between our
traditional patterns and the corresponding systems of the
In many of these
Uest to which we have been introduced.
aspects, the conflicts are being resolved through the
evolution of a new national pattern suited to our own
genius and conditions.
In medicine and health services
unfortunately, these conflicts are yet largely unresolved
and the old and new continue to exist side by side, often
in functional dishormony.
A sustained effort is, therefore
needed to resolve these conflicts and to evolve a national
system of medicine and health services, in keeping with
V
our life systems, needs and aspirations.
Plany other expert committee reports and policy statments
of the seventies began to make critical observations about
the inadequacies of the present health care model and
exhorted all concerned to search for more relevant alter
natives and approaches.
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SOME COMMUNITY HEALTH PROJECTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11,
Total Health Care Project, Assam
Community Health Project, UP
REHRAR-I-SEHAT programme, Jammu
Social Work and Research Centre,
Rajasthan
SEUA—Rural, Gujarat
Padhar Hospital Community Health
Project, Madhya Praoesh
Comprehensive Rural Health Project,
Maharashtra
Vivekananda Girijana Kaiyana Kendra,
Karnataka
Mini Health Centres Programmes of VHS,
Tamilnadu
AWARE, Andhra Pradesh
CINI, West Bengal
i„
.
!•
\
I
j ■.
J 'Li| . ,L:C
I--?'.."'
;
;
L
Ii
V
i
COMMUNITY HEALTH ACTION CENTRES
I.
Issue Raising
1.
2.
3,
11.
KSSP, Kerala
mfc, Maharashtra
AIDAN, Neu Delhi
Ne two rki ng
A.
B.
C.
D.
ACHAN, Tamilnadu
CHAI, Andhra Pradesh
CMAI, Maharashtra
VHAI , New Delhi
1.
2.
3.
4.
5.
d.
7.
RUHSfi, Tamilnadu
Deenabandu, Tamilnadu
Amb^likai, 'Tamilnadu
St John's Medical College, Karnataka
INSft/lNDIfi, Karnataka
Institute of Health Management,
Mah'arashtra
UHftI, New Delhi
CHILD-IN-NEED INSTITUTE, Vill. Daulatpur, PO Pailan
Via Joka 743512
Started in 1974—24 Paraganas, West Bengal
Population covered
: 70,000
Activities
- maternal and child health
- community organisation and
community development
Health care is through
- mahila mandal run clinics
- balwadis
- emergency ward and nutritional
rehabilitation centres
CINI has a multiplier effect with persons trained here
starting new similar projects and weaning off.
Action for Welfare & Awakening in Rural Environment (AWARE)
5-9-24/78 Lake Hill Road, Hyderabad 500463, A.P.
Started in 1975—Telegana, Andhra Pradesh
Activities
Health
— health education;
- environmental sanitation;
- disease control
— maternal and child health
— nutrition
The health philosophy 1JEEVANA SRAVANTHI* which means life's
flow started following natural disasters and led to a
sustained activity.
Services are through - Village Health Workers and Dais
- Paramedical Community Health Workers
An innovation is a floating health centre on boat, catering
to 300 villages along the banks of Godavari.
Mini Health Centres Programme of Voluntary Health Services
M.A.C. Institute of Community Health, Voluntary Health
Services, Adyar, T.T.T.I. Post, Madras 600113
Started in 1977—Chingleput Dist. Tamilnadu
o
Population covered
: 160,000
Activities
- maternity services;
- child welfare and nutrition;
- family welfare;
- minor ailment treatment
- communicable disease control
- data collection and health record
Lay first Aider (LFA)
is grass roots contact.
Multipurpose workers and part time doctors at
mini health centres.
Ayurvedic and indigenous medicines utilized.
A form of medical insurance by prepayment encouraged.
Aim at enlarging the scope of functions of the PHC.
Adopted as a model State-wide.
Vivekananda Girijana Kalyana Kendra,
B R Hills 571313
Via Chamarajanagar, Mysore District,
Karnataka
Working with Soliga tribals.
Activities
- health care;
- community organization;
- education;
- cottage industries including
vocational training;
- adult education
Health services are carried out through
medical officers,
village health workers,
traditional birth attendants,
health
education and use of traditional herbal
medicine.
Sickle cell anaemia research and
screening programme with hospital care
during
'sickle cell crisis'
of their health programme,
is a feature
while innovations
include the introduction of use of acupressure
by village health workers.
Vivekananda Girijana Kalyana Kendra,
8 R Hills 571313
Via Chamarajanagar, Mysore District,
Karnataka
Working with
Activities
Soliga tribals.
- health care;
- community organization;
o
- education;
- cottage industries including
vocational training;
- adult education
Health services are carried out through
medical officers,
village health workers,
traditional birth attendants,
health
education and use of traditional herbal
medic ine.
Sickle cell anaemia research and
screening programme with hospital care
during
'sickle cell crisis'
of their h->alth programme,
is a feature
while innovations
include the introduction of use of acupressure
by village health workers.
Comprehensive Rural Health Project, Jamkhed,
Ahmednagar Dist., Maharashtra
Started in 1970
.Population covered
40,000
Activities
: Maternal and Child Health
o
: Nutrition and immunization
: Family welfare services
: Control of Communicable diseases
: Safe water
: Agricultural development
: Health education
through young farmers clubs and
by village health workers.
Padhar Hospital Community Health Project, Betul Dist.,
Madhya Pradesh
- training of village health workers;
Activities
«
- training of dais;
- health education;
- provision of immunization, minor
medical care and family planning care.
- non-formal education in literacy,
•
agriculture and hygiene and health
It is an outre^gh programme of a mission hospital.
SEWA—Rural, Jhagadia, Bharuch, Gujarat 393110
Started in 1980—Jhagadia, Gujrat
Population
Activities
o
35,000
:
mainly health through
—community health volunteers
—anganwadi workers
—trained birth attendants
at community level;
—multipurpose workers as intermediarie
—mobile dispensary with
medical officer and MPWs
at middle level;
—fully equipped referral hospital
with consultants and paramedical
staff
at central level
SEWA-Rural has won the WHO's SASAKAWA HEALTH PRIZE for 1985.
Activities in non-health areas--
- gramini takniki kendra;
- tutorial classes for tribal boys & girls
- economic programmes for women
The Social Work and Research Centre (SURC),
Tilonia,
Ajmer District Rajasthan 305812
Started in 1973
Activities
o
- building awareness programme
- dispensary
- school health programme
- incorporation of-health into
the farmer's way of life
The local indigenous medical practitioners
and dais are involved in implementing
the programmes along with village
health workers.
REHEAR-I-SEHAT Programme, Kotbhalwal Block, Jammu & Kashmir
C/o Professor & Head, Department of Preventive and Social
Medicine, Government Medical College, Jammu 180001
A project organized by the Government of Jammu & Kashmir
to train teachers of village schools as primary health
care guides.
Activities
- minor ailment treatment;
- health check up;
- health education
- nutrition supplementation programme
for school children
Community Health Project
C/o The Director of Community Health, Harriet Benson
Memorial Hospital, Lalitpur, UP
Population
Activities
4,74,519
- Maternal and child health
- nutrition
o
- Health Education
- Communicable diseases control
through village health workers from
the c ommun i ty.
Total Health Care Project, Tamulpur Block,
Kamrup Dist,
Assam
Started in 1976—in 204 villa es of the Block.
Activities
o
- basic health services like:
family planning
immunization;
treatment of minor ailments^
control of tuberculosis,
leprosy;
malaria
Mallur Health Co-operative, Mallur, Sidlaghatta Taluk, Kolar Dist.
Karns' aka
Started—1973
Population covered
Activities
- dairy cooperative
- preventive
)
, .
- promotive
x health service with Government
)
. .
- curative
x health centre
)
Dairy cooperative took up health responsibility of the village
which evolved into a health endowment fund to cater to all
health needs.
Integrated Health Services Project
Wanless Hospital, Miraj Medical Centre, Miraj, Maharashtra
Started in________
Miraj Taluk
Population
2,30,329
Activities
- Maternal and child health care
- family planning
- school health
- communicable '-'disease control
- environmental sanitation
- health education
using Basic Health Workers, Dais,
ANMs and Village Health Assistants.
The Rural Health Research Project of
Foundation for Research in Community Health (FRCH),
48A, Abdul Gaffar Khan Road, Worli, Bombay, Maharashtra
Started in 1973—North Alibag and Uran Taluk, Maharashtra
Population covered
: 90,000
Activities
- community organization
- maternal and child health care
- health education
- treatment of minor ailnfents
through village health workers and
with the Primary Health Unit as the
apex of preventive, promotive
and curative health care.
Comprehensive Health Project, Rangabelia,
Rangabelia High School, Rangabelia PO,
24 Pargana, W. Bengal
Started in 1976—Rangabelia
Activities
- maternal and child health care
- communicable disease control
- minor ailment treatment
- family welfare services
- housing, safe drinking water,
sanitation
- health education
in close collaboration with the
health services of the government.
PROJECT POSHAK, Programme Evaluation Organization
27 Alkapuri, Baroda
Population covered
10 tibal + 2 non-tribal Districts
of Madhya Pradesh
12,000 children + 2,700 women
Activities
: Take home food supplements
From 1971 to 1975
: Preventive & curative
health services
: Maternal and Child care educatioi
- by utilising the existing
health and tribal welfare
infrastructure of the
government.
THE KASA MODEL MOTHER-CHILD-HEALTH-NUTRITION PROJECT
C/o Grant Medical College and JJ Group of Hospitals
(Institute of Child Health), Bombay
Started in 1972—Palghar, PHC, Kasa, Thana Dist, Maharashtra
Population
56,364
Activities
- integrated health and nutrition
services to young children and mothers
by using existing primary health centre
services and personnel along with
part time social workers (PTSWs)
serving as link workers and providing
special coverage to the needy at
clinics or at home.
INDO-DUTCH Project for Child Welfare
C/o The Director, Indian Bureau, Indo-Dutch Project
for Child Welfare, 6-3-885 Somajiguda, Hyderabad
Started in 1969
Population
33,756
Activities
- mother and child care—health
education and nutrition
- mahila mandals
- nursery and primary schools
- youth development/adult education
- nutrition demonstration units
- poultry and dairy units
"Gram Svasthikas" are the link between the community
and health services.
INDO-DUTCH Project for Child Welfare
C/o The Director, Indian Bureau, Indo-Dutch Project
for Child Welfare, 6-3-885 Somajiguda, Hyderabad
Started in 1969
Population
33,756
Activities
- mother and child care—health
education and nutrition
- mahila mandals
- nursery and primary schools
- youth development/adult education
- nutrition demonstration units
- poultry and dairy units
"Gram Svasthikas" are the link between the community
and health services.
Comprehensive Health and Development Project, Pachod, Aurangabad
Maharashtra
Started in
Activities
- maternity care;
- health and nutrition education;
- groxvth monitoring and nutritional
surveillance of children;
- environmental programmes through
community health workers.
- training course in management
of small health projects.
The health education materials are locally developed and
are unsophisticated.
appropriate and brief.
BANWASI SEVA ASHRAM, Govindpur, Dist Mirzapur, UP
Started in 1954—Mirzapur District
Population covered
; 3,50,000
Activities
; agriculture
: dairy
: village industries;
: education;
: gram kosh (revolving village fund for
cheap credit)
: social justice programmes
Health and family planning activities through
- swasthya mitra (local volunteers)
- gramin doctors (at village health posts)
- AGRINDUS clinics
Based on Gandhian philosophy of self-sufficiency with
AGRINDUS (Agro Industrial Community Development Centre)
nucleus of its diverse activities.
as the
BODOKHONI
Activities
- adult education
- informal education
taking up health issues for action
- grain bank
- savings scheme
- goat rearing
- non formal school for children
through health animators who believe that
these are as important as disease
treatment and manage common ailments.
They work with -- aramya sangha (men's organization)
- mahila sangha (women's organization)
Rural Unit for Health and Social Action (RUHSA)
Christian Medical College & Hospital, RUHSA Campus PO
N.A. Dist, Tamil Nadu 632209
Started in 1977—K.V. Kuppam Block, Tamilnadu
Population covered
:
Activities
- health and family welfare;
100,000
- adult education;
- vocational training
- community organisation;
- income generation
- agricultural development and agro-support
services
- training procrammes in community health
The health component is by
- family care volunteers (FCVs)
- health aides (HAs) and
- rural community organisers
with close health and non-health
activity linkages.
They believe that Health is both a MEANS and MEASURE of
development.
COMPREHENSIVE LABOUR WELFARE SCHEME (CLWS) OF
UNITED PLANTERS ASSOCIATION OF SOUTHERN INDIA (UPASI),
Glenview, Coonoor 643101, Tamil Nadu
Started in 1971—Plantations in Tamilnadu and Kerala
Population covered
:
Activities
o
- maternal and child health;
250,000 (1984)
- family planning;
- environmental sanitation;
- safe drinking water;
- health education.
Voluntary'LINK WORKERS1form the key element linking the
community to health services.
Has sensitized the management to the idea that employee's
health and welfare is congruent with employer's interests
KEM Hospital Vadu Rural Health Project, Sardar Mudliar Road
Rasta Peth, Pune 411011
Started in 1977—Pune District, Maharashtra
Activities
: maternal and child health;
family planning;
control of communicable diseases;
health education;
environmental sanitation;
mahila mandal, youth clubs—
awareness programmes.
Health activities through
- community health guides of
KEM Rural Health Project;
- multipurpose workers of
government cadre;
- upgraded PHC at Vadu—at secondary
level;
- KEM Hospital—at tertiary level.
Socio economic development programmes are with a closely
linked voluntary organisation—United Socio-economic
Development and Research Programme (UNDARP).
STREEHITAKARINI, Dadar, Bombay
Started in 1974—Slums of Bombay City
Population covered
: 100,000
Activities
: maternal and child health;
family planning services by
volunteer doctors;
o
non-formal education;
female literacy;
income generation programmes for wome
creches for under fives;
small savings scheme (this won the
government campaign award for 1985);
Health activities through
- community health workers;
- utilization of nearest
government hospitals
Stress on creating awareness about health and promoting
utilization of facilities available.
R.A.H.A. - Raigarh Ambikapur Health Association
C/o Bishop's House, PO Kunkuri, Raigarh Dt Madhya Pradesh 496225
Started in
Population covered
Activities
- a network of 3 base hospitals
and 47 rural health centres;
- all aspects of health;
- school health programmes with
voluntary school health guides from
school teachers
- tuberculosis control programme;
innovative medical insurance scheme.
The Nilniri
Adivasi Welfare Association,
Kota Hall Road, Kotaoiri,
Fair GJ on Annexe,
Niloiris 543217
Started in 1958 - Tribals
Activities
- nut rit io n;
- health education;
- adult education
- income generating projects in cooperation
with government,
bank ano voluntary bodies
- rehabilitation of tribals keeping in view
their varied stages of development
survival problems
and
MEDICARE,
Kasturba Medical College,
Manipal,
Karnataka
— a project of the medical college
Activities
- conducting a rural maternity and
child welfare home each in seven
centres at a distance of 3 to 20 miles
from the hospital.
- health education;
- safe water supply and sewage disposal
with the help of Panchayat;
- immunization;
- pest control measures
family welfare programmes
St Xavier's Social
Opp.
Services Organization,
St Xavier's Loyola Hall,
Ahmedabad 380009
Wording in the slums of Ahmeoaoad.
0
Activities
- community organization;
- income generation programmes;
- health activities in the areas o£--
nut rit io n;
antenatal care;
infectious diseases;
family planning;methods
health education.
1 0 APR 1990
Cc r'\ V A '
b
HEALTH CARE SERVICES IN INDIA
Facts Revealing Gross Maldistribution
The health care service planning in India is characterised by its
failure to take into account the holistic picture of the health
care services.
In the mixed economy model the social sector is
planned with a view to provide for the externality and to
redistribute the services in favour of the underprivileged masses.
This is precisely what has not happened in the planning process
simply because the planning commission never has had a holisticpicture of the size, distribution and growth trends in the health
care service.
The single most important reason for the lack of
holistic concept and approach is its failure to take into account
the private sector in health care services.
What follows is a preliminary attempt to estimate the size of and
the growth trends in the private health care sector, and the same
are
compared with the
public health care
sector.
Their
distribution between the rural and the urban areas are also
examined.
The data are presented in the following three sections
A.
Health Humanpower
B.
Health Care Infrastructure
C,
Financing of Health Care Services.
THE FBUNDAT10N FOR RESEARCH
IN COMMUNITY HEALTH
^4-A. R, G, Thadanr Marg. Sea Face Corner
Wodi Bombay-400 018 J N D1 A
Section A : Health Humanpower
a.
Doctors and Nurses : Number Registered (Table A-l).
1.
In 1986, there were 7,63,437 doctors of all systems of
medicine in India.
This comes to one doctor for less
than 1000 population.
2.
Of all doctors, the allopathic doctors constituted only
42% in 1986.
3.
In 1986,
there were 3,92,670 nurses and midwives in
India.
4.
There was only ONE nursing person for TWO doctors in
India in 1986. The situation demands more than reversal
of the ratio i.e. about 4 nurses per doctor.
5.
In addition there were 1,08,511 ANMs,
88,308 MPWs,
18,819
Female
Health
Assistants in
1987
(Total
2,45,369).
Together
with nursing
personnel,
the
paramedical human power was 6,38,039.
This is grossly
inadequate.
b.
Doctors and Nurses : Rural-urban distribution (Table A-2 and
A-3)
1.
In 1981 (census data), only 41% of all doctors and 43%
of all nurses/midwives were located in rural areas,
while 76.3 of the population was rural.
2.
Situation is the worst for allopathic doctors and
nurses.
In 1981 only 27% of allopathic doctors and only
31% of nurses were located in rural areas.
3.
Over last three decades (1961, 1971, 1981 census data)
there is progressive "deruralisation" of doctors and
nurses .
c.
Doctors : Public-Private Sector distribution (Table A-4)
1.
There is an increasing concentration of allopathic
doctors in the private sector (Table A-4 covers mainly
allopathic doctors).
2.
In 1986-87, about 73% of allopathic doctors were working
in the private sector.
3.
When the number of doctors employed in the public sector
is taken as proportion of total doctors of all systems
of medicine, we find that only 13 to 18% are employed
with the government or local bodies, the rest being in
the private sector.
4.
Of all doctors in the private sector 85 to 90% are selfemployed or doing private practice.
Medical
A-6)
1.
2.
3.
4.
and Nursing Education Infrastructure (Tables A-5 and
In 1986, there were 123 allopathic medical colleges in
India, of which 17% were in the private sector.
Between 1974 and 1986,
the proportion of
private
allopathic medical colleges increased from 8.5% to
17.1%.
In 1986 there were 222 medical colleges for other
systems of medicine of which 65% were in the private
sector.
The admission capacity for those colleges was,
10,521 per year, of which 67% admission accounted for by
the private colleges.
As compared to medical colleges,
there were only 8
institutions for B.Sc nursing and 324 for general
nursing education.
Out-turn of Medical and Nursing Personnels (Table A-7)
1.
India produces around 15,000 allopathic and 5,000 to
10,000 non-allopathic doctors per annum.
2.
In
comparison,
about
10,000
nursing
personnel
3.
(nurses/midwives) are trained per annum.
About 15 to 20% of allopathic doctors produced
year, migrate to some other country.
every
Table Al: MEDICAL AND NURSING HUMANPOWER IN INDIA (1952-87)
1952
1956
1961
1966
1969
1971
1974
1979
1981
1984
1985
1986
1987
SOURCE
65370
76904
83756
103184
128584
151129
190838
249752
268712
297228
306966
319254
330755
.
doctors_____________
HOMOEO
PATHS
AYURVEDS
SIDHA
UNANI
TOTAL
NA
NA
27468
NA
110514
NA
145434
112638
115710
123852
123852
131091
NA
NA
NA
73382
NA
155828
NA
223109
225477
233824
251071
251071
272800
NA
NA
NA
NA
NA
NA
NA
18128
18093
18357
11352
11352
11581
NA
NA
NA
NA
NA
24530
NA
30400
25988
28737
28382
28382
28711
NA
184606
419456
607909
631948
665340
711885
721623
763437
-
DENTISTS _____ PARAMEDICS____
MIDWIVES
NURSES
TOTAL
17989
24724
35584
57621
69937
80620
98403
139825
154230
170888
197735
207430
NA
86778
160779
198957
270207
299050
339381
369325
392670
-
3291
3003
3582
4374
5182
5512
6647
7518
8648
8725
9598
9725
9750
Health Statistics of India, CBHI, GOI relevant years.
NA
NA
51194$
NA
NA
80159
'100554
130382
144820
168493
171590
185240
NA
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
REFERENCE
YEARS
ALLOPATHS
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
Table
A2 : RURAL-URBAN DISTRIBUTION OF MEDICAL HUMANPOWER IN INDIA
REFERENCE
YEARS
1961
R
U
T
1971
R
U
T
1981
R
U
T
TOTAL
ALLOPATHS
HOMOEO
PATHS
AYURVEDS
80484
(48.7)
84787
(51.3)
165271
(100.0)
19187
(29.5)
45837
(70.5)
65024
(100.0)
16185
(52.4)
11075
(40.6)
27260
(100.0)
45112
(61.8)
27875
(38.2)
72987
(100.0)
114354
(49.4)
117154
(50.6)
231508
(100.0)
49846
(39.4)
76507
(60.6)
126353
(100.0)
23527
(61.2)
14917
(38.8)
38444
(100.0)
36871
(62.6)
21994
(37.4)
58865
(100.0)
4110
(52.4)
3736
(47.6)
7846
(100.0)
124426
(39.2)
192643
(60.8)
317069
(100.0)
53407
(27.2)
143147
(72.8)
196554
(100.0)
31916
(63.7)
18188
(36.3)
50104
(100.0)
36503
(57.3)
27211
(42.7)
63714
(100.0)
2600
(38.8)
4097
(61.2)
6697
(100.0)
Source :
Census 1961, 1971, 1981, GOI.
Notes :
;
T = Total
R = Rural ;;
U = Urban
Figures in parentheses are percentages.
UNANI
-
-
Unani practitioners were not covered separately by the
1961 Census.
Sidha medical practitioners were not
covered by the census.
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
Table A3
: RURAL-URBAN DISTRIBUTION OF NURSES AND OTHER
PARAMEDICAL HUMANPOWER IN INDIA :
REFERENCE
YEARS
1961
R
U
T
1971
R
U
T
1981
R
U
T
TOTAL
NURSES
MIDWIVES &
HEALTH
VISITORS
63078
(49.5)
64325
(50.5)
127403
(100.0)
29098
(38.2)
47111
(61.8)
76209
(100.0)
33980
(66.4)
17214
(33.6)
51194
(100.0)
55425
(39.6)
84505
(60.4)
139930
(100.0)
31711
(30.6)
71899
(69.4)
103610
(100.0)
23714
(65.3)
12606
(34.7)
36320
(100.0)
81980
(37.8)
134787
(62.2)
216767
(100.0)
52275
(31.3)
114913
(68.7)
167188
(100.0)
29705
(59.9)
19874
(40.1)
49579
(100.0)
Source : Census 1961, 1971, 1981, GOI.
Notes
: R = Rural ; U = Urban ; T = Total.
Figures in parentheses are percentages.
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
Table A4:
Year
1942-43
1963-64
1978-79
1984-85
1986-87
SECTORAL EMPLOYMENT OF ALLOPATHIC DOCTORS IN INDIA
Government
Service
13000
39687
69137
81030
88105
(27.4) .
(39.6)
(29.3)
(27.4)
(26.6)
Private
Sector
34400
60502
166494
214799
242650
(72.6)
(60.4)
(70.6)
(72.6)
(73.4)
Total
47400a
100189b
235631c
295829c
330755c
(100.0)
(100.0)
(100.0)
(100.0)
(100.0)
Sources:
a) Report of the Health Survey and Development
Committee (Bhore Committee), 1943, Vol.I, pg. 13.
b) IAMR-NIHAE "Stock of Allopathic doctors in India",
1966, pg. 71-72.
c) Health Statistics of India - 1979, CBHI, GOI.
Health Information of India - 1985, 1988, CBHI, GOI.
Notes :
Figures in parentheses are percentages.
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
Table A5.
REFERENCE
YEARS
1950
1951
1952
1956
1961
1966
1969
1974
1979
1983
1984
1985
1986
1987
: MEDICAL EDUCATION INFRASTRUCTURE IN ^NDIA
(Allopathic doctors, Dentists and Nurses)
MEDICAL COLLEGES
NO. % PRIVATE
28
30
30
46
68
89
95
105
107
111
116
121
123
125
3.57
6.66
6.66
6.52
4.41
8.98
9.47
8.57
9.34
10.81
14.65
15.70
17.07
NA
(1950-86)
DENTAL
COLLEGES
NURSING
B.Sc.
INSTITUTIONS
GENERAL
4
4
5
7
12
14
15
15
17
25
25
29
36
40
2
2
2
2
6
8
8
8
8
8
NA
NA
NA
NA
227
246
235
239
202
246
251
262
275
324
344
374
386
NA
SOURCE : Health Statistics of India, CBHI, GOI relevant years.
Medical Education in India, CBHI, GOI, 1987 .
Handbook of Medical Education in India , Association of
Indian Universities, 1987.
Notes
: NA = Not Available
TABLE A6 : MEDICAL EDUCATION INFRASTRUCTURE=AS ON APRIL 1, 1986.
(Doctors of Indian Systems of Medicine and Homeopathy)*
Ayurveda
Unani
Siddha
Homeopathy
Source
ADMISSION CAPACITY
PRIVATE
TOTAL
GOVERNMENT
1813
4595
(77.7)
3882
(100.0)
576
(100.0)
150
(100.0)
5913
(100.0)
7181
(67.3)
10521
(100.0)
3970
1716
(44.2)
256
(44.4)
150
(100.0)
1318
(22.3)
2166
(55.8)
420
(55.6)
-
79
(75.2)
98
(100.0)
17
(100.0)
2
(100.0)
105
(100.0)
144
(64.9)
222
(100.0)
3440
(32.7)
44
(45.0)
6
(35.3)
2
(100.0)
26
(24.8)
54
(55.0)
11
(64.7)
-
78
(35.1)
OUTTURN. (19851
TOTAL
539
49
1769
: Compiled from "Indian Systems of Medicine and Homeopathy in India ■ 1986"
published by Planning and Evaulation cell of the Ministry of Health and
Family Welfare, New Delhi.
* The data are^complete due to non-reporting by many states and
institutions.
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
MEDICAL COLLEGES
PRIVATE
TOTAL
GOVERNMENT
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
Table A7 : OUTTURN OF ALLOPATHIC MEDICAL AND NURSING PERSONNEL
IN INDIA (1950-1987).
REFERENCE
YEARS
ALLOPATHS
DENTISTS
1950
1955
1960
1965
1970
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1557
2743
3387
5387
10407
11962
13783
12190*
13083
12170*
12197*
11992*
10511
10469*
9177*
NA
NA
14
31
140
294
478
499
449
466
515
501
488
541
603
662
567
677
660
POST GRADUATES
(ALLOPATHS &
DENTISTS)
88
110
397
791
1396
2265
3694
3699
3562
3759
3833
3940
4161
4909
5121
5427
5791
NURSES
B.Sc. GENERAL
14
21
25
67
101
184
190
240
219
263
214
240
315
NA
NA
NA
NA
1282
1962
2562
4255
6257
5506
5892
6788
6503
7256
8144
7351
7750
8533
8956
8208
NA
SOURCE : Health Information of India, CBHI, GOI, various years.
Notes
:*
Data on the outturn of allopaths was not received from
2 medical colleges in 1975-76, 1 in 1976-77, 2 in
1977-78, 6 in 1981-82, 7 in 1982-83, 14 in 1983-84, 15
in 1984-85 and 25 in 1985-86. Thus, the data is
grossly underrated.
NA = Not Available.
Section B : Health Care Infrastructure
a.
Number
1.
b.
In 1988 there were 9381 hospitals, 27495 dispensaries,
14,145 PHCs and 5,85,889 hospital beds in the country.
Rural-Urban Distribution (Table B-l)
1.
2.
In 1988, 31.5% of hospitals, 47.3% of dispensaries and
15.8% of hospital beds were located in the rural areas.
In 1988 there was one hospital bed for 363 persons in
the urban area and for 1034 persons in the rural area.
c.
Public-Private Sector Distribution of Hospitals and Hospital
Beds (Tables B-2 and B-3)
1.
In 1988, 56% of hospitals and 30% of hospital beds were
located in the private sector.
2.
However, since 1974, the growth of the private sector in
hospitals and hospital beds has been phenomenal, about 8
to 10 times that in the public sector.
d.
Public-Private
Sector Distribution of
Dispensaries and
Dispensary Beds (Tables B-4 and B-6)
1.
In 1988, 49.4% of dispensaries and 9.2% of dispensary
beds were located in the private sector.
2.
However,
the
growth
of private
dispensaries is
phenomenal.
The proportion of private dispensaries
increased from 13.8% in 1981 to 49.4% in 1988.
The
annual growth rate of private dispensaries between 198184 was 68% and between 84-88 it was 28%.
3.
The absolute number of dispensary beds have declined in
both the sectors.
Table Bl :
HEALTH INFRASTRUCTURE IN INDIA : RURAL-URBAN DISTRIBUTION (1951-88)
Hospital Beds
(Excl. PHC.)
Hospitals
Dispensaries
1951
1956
1961
1966
1969
1974
1979
1983
1988
2694
3307
3054
3971
4023
4014
5766
6901
9381
6587
7194
9406
10231
10440
10200
15968
17455
27495
Source:
Health Statistics of India, CBHI, GOI, various years.
Statistical Abstract 1984, CSO, GOI, 1985.
Directory of Hospitals in India, CBHI, GOI, 1981.
Notes :
Figures in parentheses are percent rural.
NK = Not Known
*
includes Subsidiary Health Centres also.
**
Data relates to the year 1986 when total number of
555264.
(NK)
(39.3)
(32.8)
(32.5)
(30.7)
(25.2)
(25.6)
(26.4)
(31.5)
(79.4)
(84.1)
(53.1)
(78.9)
(79.1)
(71.6)
(69.8)
(68.6)
(47.3)
0
725
2565
4631
4919
5283
5423
5954
14145*
117000
145297
229634
306518
328323
341064
446605
486805
585889
(NK)
(23.0)
(15.8)
(18.0)
(21.0)
(11.2)
(13.1)
(13.5)
(15.8)
Poon. per bed
Urban
Rural
487
343
306
310
358
338
369
363**
2272
1589
1308
1295
1424
1139
1109
1034**
hospital beds was
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
PHCs
(only Rural)
Ref.
Years
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
TABLE B2 : OWNERSHIP STATUS OF HOSPITALS AND HOSPITAL BEDS
Ref.
Years
_______ HOSPITALS________
Govern
Private Total
ment
1974
2832
(81.4)
3735
(64.7)
3747
(56.2)
3925
(54.6)
4093
(54.7)
4215
(54.3)
4334
(44.1)
1979
1981
1984
1986
1987
1988
644
(18.6)
2031
(35.3)
2923
(43.8)
3256
(45.4)
3381
(45.3)
3549
(45.7)
5497
(55.9)
3476
(100.0)
5766
(100.0)
6670
(100.0)
7181
(100.0)
7474
(100.0)
7764
(100.0)
9831
(100.0)
_
______ HOSPITAL BEDS
GovernPrivate
Total
ment
211335
(78.5)
331233
(74.2)
334049
(71.5)
362966
(72.5)
394553
(73.9)
411255
(74.1)
410772
(70.1)
57550
(21.5)
115372
(25.8)
132628
(28.4)
137662
(27.5)
141182
(26.1)
144009
(25.9)
175117
(29.9)
268885
(100.0)
446605
(100.0)
466677
(100.0)
500628
(100.0)
533735
(100.0)
555264
(100.0)
585889
(100.0)
Source : Health Information of India, CBHI, GOI, various years.
Directory of Hospitals in India, CBHI, DGHS, GOI, 1981.
Notes
: Figures in parentheses denote percentages
Government figures include ownership by local bodies.
Data on the number and ownership status of hospitals and
beds were not reported by 6 states in 1974, 5 in 1979, 1
in 1981, 1984, 1986, 1987 and 1988.
Madhya Pradesh has not reported its data since 1979.
____
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
TABLE B3 : RATE OF GROWTH OF HOSPITALS AND HOSPITAL BEDS (BY
OWNERSHIP)
Reference
Years
1974-79
1979-84
1984-88
______ Hospitals______
Government
Private
6.37
1.02
2.61
43.07
12.06
17.21
Source : Same as Table B2.
Notes
: Figures are in percentages.
_____ Hospital Beds
Government
Private
11 . 35
1.92
3.29
20.09
3.86
6.81
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
TABLE B4 : OWNERSHIP STATUS OF DISPENSARIES AND DISPENSARY BEDS
DISPENSARY BEDS
DISPENSARY
Ref.
Years
Govern
ment
Private
Total
Govern
ment
Private
Total
1981
13205
(86.2)
14694
(69.5)
13916
(50.6)
2115
(13.8)
6438
(30.5)
13579
(49.4)
15968 a
(100.0)
21780 a
(100.0)
27495
(100.0)
26231
(95.2)
30251
(85.1)
21659
(90.8)
1314
(4.8)
5306
(14.9)
2187
(9.2)
277306 b
(100.0)
35742 b
(100.0)
23846
(100.0)
1984
1988
Source : Same as Table B2.
Notes
: Government figures include ownership by local bodies.
a) Ownership details for 648 dispensaries was not
available.
b) Ownership details for 185 dispensary beds was not
available.
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
TABLE B5 : RATE OF GROWTH OF DISPENSARIES AND BEDS (BY OWNERSHIP)
Ref.
Year
1981-84
1984-88
.
_ DISPENSARY______
Government
Private
0.26
-1.32
68.13
27.73
DISPENSARY BEDS
Government
Private
5.11
-7.11
101.26
-14.69
Source : Same as Table B2.
Notes
: Government figures include ownership by local bodies.
Section C : Financing of Health Care Services
Source of Financing
1.
2.
3.
4.
5.
6.
7.
8.
State : General health services
State : Special health services (eg. Railways, Defense etc).
State Insurance : ESIS/CGHS
Local Bodies : Municipal Cooperations, Municipalities, Zilla
Parishads and Panchayat Samitis
Private Insurance : Mediclaim, group insurance, etc, through
public insurance companies.
Private Prepayment schemes : Select hospitals etc.
Private Corporate Sector :
Health benefits - contributory/
non-contributory given to employees.
Households
: Out of pocket expenditure by families mainly
financing private practice.
Estimates of Financing by different source
The only definite figure of health care finance is the one for
general health services by the State (Central,
State & Union
Territory governments).
This includes Medical Services, Medical
Education & Research, health services administration, expenditure
on
non-allopathic
systems,
communicable disease
programs,
watersupply,
sanitation & sewerage,
education & training of
paramedics,
MCH services and the family planning program.
This
data is compiled in the "Combined Finance and Revenue Accounts" by
the Comptroller & Auditor General of India.
Tables C-l and C-2 give a brief outline of this source of health
financing.
Table C-l gives data for select years (every five
years since 1951) and Table C-2 gives the complete data from Plan
one to Plan six (partly, because of non-availability of source
material)
as five year data and annual averages for
the
respective plan period.
These tables reveal that state expenditure of health care services
is a very negligible contribution for people's welfare. During
the First Plan period this was only 0.39% of GNP and at present it
is less than 1.4% of GNP.
Even as a proportion of its own total
expenditure the government has been spending only between 3 and 4%
on health services, which as indicated above includes not only
medical services but also family planning and water supply.
For a
country that proclaims socialist or a mixed economy this is a very
poor proformance.
The major demand and need of the population is curative services
and this is the least provided by the state sector.
What little
is provided as curative care is mainly in urban areas.
Sections A
& B have already dealt with''this disparity.
This need for curative services is met by a large and expanding
private health sector.
There is no definite data of the financing
of the private health sector.
What is known is that 73% of
allopathic doctors work in the private sector and of this 88% are
in private practice.
The private health sector is financed directly by households - in
case of about half the organised sector some subsidies in the
forms of employer or insurance health benefits exist (which in
fact is nothing but social wages).
No organised data about the
volume of such financing is available.
On the eve of the First Five Year Plan the National Sample Survey
recorded private health expenditure (by households) as Rs.
5.77
per capita per annum in 1951.
This was 6 times of what the State
sector was spening at that time.
Again in 1973-74 the NSS
recorded private health expenditure as Rs. 14.05 per capita per
annum which was three times greater than the state health
expenditure in the same year.
Besides this some scattered data based on small studies exists.
Of these the most organised study was in Narangwal by R.L. Parker
which showed that private health expenditure varied between 3 and
6 times of state health expenditure in the late sixties and early
seventies.
A study by FRCH in 1987 in Jalgaon district in Maharashtra showed
that households were spending out of pocket Rs. 174.99 per capita
per year obtaining health care services - this was 5.75% of their
income.
This expenditure was 6.7 times over and above the state
health expenditure of Rs. 26.09 per capita (0.85% of income)
in
Jalgaon (see Table 0-3).
As a contrast even in capitalist USA the
state account for as much as 40% of all health expenditure.
Besides such data no ther data is available for this source of
financing of health services which is the most important because
of its sheer magnitude.
Data on other private sources like
corporate financing,
private insurance etc.
suffers the same
fate.
Local body financing of health care services constitutes
another important public source of funding.
This data is not well
organised but it is possible to organised it if the state is
willing to compile it,
Table C-4).
like in the
case of State
Finances (see
Similarly corporate sector health benefits to employees can be
obtained if the state insists that all companies issuing Annual
Reports should show this item of expenditure separately.
Table C-l : State Health Expenditure in India : 1951-1989.
(Rupees Millions)
3 *
Family
Welfare
7
6
Per capita Col.4 as
of Col.4
% of govt.
Expenditure
(Rs.)
4
Health
(1+2+3)
5 **
% Plan Health
Expenditure
Col. 4
221.41
No Plan
0.61
2.31
0.22
5.08
5.30.36
43.17
1.32
3.54
(10.65)
0.45
(20.91)
423.69
16.00
1032.82
52.38
2.35
3.74
(1.13)
0.65
(8.89)
1011.88
731.58
49.80
1793.26
39.76
3.63
2.79
(-5.08)
0.65
(0.0)
1971
1378.00
1612.40
556.00
3546.40
60.48
6.47
3.45
(4.73)
0.82
(5.23)
1976
4445.31
2684.79
822.40
7952.50
58.95
12.88
.3.76
(1.80)
0.99
(4.15)
1981
8769.18
7350.95
1464.02
17584.15
41.47
25.66
4.05
(1.54)
10.10
(2.22)
1983
11931.62
10486.59
2946.17
25364.38
57.83
35.46
4.37
(2.63)
1.43
(10.00)
(FW Year book 87-88)
1986
5365.00
39865.00
51.77
1.37
(-1.40)
(Estd.)
1989
7100.00
52000.00
64.45
1.34
(-0.73)
2
Public
Health
1951
149.19
72.22
1956
305.88
219.40
1961
593.13
1966
*
**
8
Col.4 as
% of GNP
F.P. figures
from 1956-71 are average of Plan Period. Prior to 1974 FP was part of
"Medical". Hence for those years we have deducted this average figure from "Medical".
Based on average of plan period. Figures in brackets are growth rate per year over the
previous year.
Sources : 1.
2.
Combined Finance and Revenue Accounts, Comptroller & Auditor General of India,
GOI, respective years.
Report or Currency & Finance; 1988 Vol.II, RBI, 1989.
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
1
Financial
Year End
March
Medical
Table C-2 : State Health Expenditure 1951-52 to 1982-83 : Plan + Non-Plan
(Figures in parentheses are annual averages)
(Rupees Millions)
1
Medical
2
Public
Health
Plan One
1951-52 to 55-56
1246.45
(249.29)
725.10
(145.02)
Plan Two
1956-57 to 60-61
2306.30
(461.26)
Plan Three
1961-62 to 65-66
3889.40
(777.88)
3
Family
Welfare
4
Health
(1+2+3)
5
% Plan
of Col.
4 Expd.
1.45
(0.29)
197.3.00
(394.60)
50.48
outlay
60728.55 3.25
(12145.71)
1.04
0.39
1609.10
(321.82)
22.00
(4.4)
3937.40
(787.48)
69.59
outlay
115266.75 3.42
(23053.35)
1.88
0.59
2985.45
(597.09)
249.00
(49.80)
7123.85
(1424.77)
50.05
251871.95 2.83
(50374.39)
3.07
0.71
Plan Holiday
1966-67 to 68-69
3403.35
3127.50
(1134.45) (1042.50)
705.00
(235.00)
7235.85
(2411.95)
43.30
235365.03 3.07
(78455.01)
4.76
0.78
Plan Four
1969-70 to 73-74
11065.10
8495.55
(2213.02) (1699.11)
2824.15
(564.83)
22384.80
(4476.96)
47.91
598754.80' 3.74
(119750.96)
8.22
0.83
Plan Five
1974-75 to 78-79
25639.70 16350.95
5292.55
(5127.94) (3270.19) (1058.51)
47283.20
(9456.64)
49.58
1194988.35 3.96
(238997.67)
15.25
1.18
Part Plan Six
1979-80 to 82-83
(4 yrs.)
38510.80 32553.72
7551.24
(9627.70) (8138.43) (1887.81)
78615.76
(19653.94)
52.15
(est)
1862023.72 4.22
(465505.93)
28.60
1.40
Sources : as Table C-l.
6
Total
Govt.
Expnd.
7
8
9
% Col. per
Col.4
4 of
Capita as %
Col.6 of col. of GNP
4 (Rs)
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
Plan Period
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
Table C-3
:
Classwise Distributicn of Health Expenditure and Other Selected Variables in
Jalgaon District - 1987.
GLASS
Variable
Poorest
Lower
middle
Middle
Upper
middle
Richest
All
classes
a) Mean cost per episode (Rupees)
’ 32.01
90.02
130.44
207.01
102.81
102.14
i.
Practitioner Fees & Medicine
28.21
63.46
87.04
167.44
90.26
69.97
ii.
Diagnostic Tests
0.16
6.43
8.95
5.73
0.00
5.13
0.43
10.14
17.47
19.76
0.00
11.10
iii. Hospitalisation and surgery
iv.
Transport
2.14
7.86
10.89
6.86
0.96
7.43
v.
Rituals
0.19
0.76
3.00
1.00
8.42
1.48
vi.
Others____________________
0.88
1.37
3.08
6.22
3.17
2.23
vii. Non-users of any service (%)
13.77
8.45
6.28
4.05
5.00
7.70
b) Mean cost per contact (Rs.)
13.06
31.92
43.05
62.17
51.15
36.09
c) Mean Health Expenditure per
capita per year (Rs.)
50.77
151.07
256.49
417.04
367.48
182.49
43.51
88.03
156.71
235.80
109.92
116.31
17.69
32.85
55.77
76.81
61.41
43.24
iii. Per capita Per year
69.00
147.73
308.14
475.04
392.91
207.80
iv.
Private users (%}
72.19
75.38
80.27
85.13
95.00
77.09
e) Health Expenditure as a percent
of Income
6.50
10.50
10.20
10.20
5.60
9.80
f) Disease Prevalence Rate - per
1000 population per month.
132.15
139.85
163.86
167.88
297.87
148.89
g) Total population in survey
681
1566
891
274
47
3459
h) Total no. of patient's (monthly
average).
90.
219
146
46
14
515
d) Mean cost for use of private
services (Rs.)
i.
Per episode
ii.
Sources
Per contact
"Cost of Health Care : A Household Survey in an Indian District" by Ravi Duggal
with Suchetha Amin.
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
Oonplled by Ravi Duggal - November 1989
Table C-4 : MUNICIPAL HEALTH FINANCE - (Medical + Public Health + Water Supply & Sanitation)
(All India)
Year
Rs. million
Municipal Bodies
Rs. million
District Board
Source
Remarks
1951-52
121.52 (30% of Income)
21.45(6.3% of)
Income)
GOI, Health
Stats of India
Incomplete information
population not known
1952-53
161.74 (31.8%
)
13.79 (4.0%)
••
••
1953-54
89.00 (30.5%
)
11.00 (4.9%)
••
••
1954-55
146.71 (32.7%
)
11.31 (2.0%)
••
••
1955-56
156.02 (29.4%
)
4.09 (2.6%)
1956-57
111.93 (32.0%
)
NA
1957-58
93.35 (32.7%
)
NA
••
1959-60
355.23 (50.9%
)
16.24 (6.63%)
••
1960-61
263.71 (53.64%
)
9.20 (6.11%)
1970-71
530.97 (35.0% of
total expnd.)
1974-75
2155.89 (40.2%
”
'■
1976-77
1294.33 (37.8%
"
1979-80
1986-87
"
••
••
••
NA
NCAER
Rs.24.68 per capita
(sample 21.5 million
population in 12
Municipal Corporation
and 27 Municipalities)
)
NA
NIUA-1983
Rs.26.71 per capita
(sample 1533 municipal
bodies covering 80.7
million population)
"
)
NA
NCAER
Rs.48.08 per capita
(sample 26.9 million
population in 12
Municipal Corporation
and 27 Municipalities)
3791.84 (37.8.3% "
"
)
NA
NIUA-1983
Rs. 33.47 per capita
(Sample 1533 Municipal
bodies with 113.27
million population)
2270.00 (38%
"
)
NA
NIUA-1989
Rs.55 per capita (sample
41.2 million papulation
of 157 Class I municipal
bodies)
Sources
GOI - Health Statistics of India, Various years DGHS, MOHFW, Delhi.
NCAER - A Study of Resource of Municipal Bodies, 1980, New Delid.
NIUA - 1983 - A Study of Financial Resources of Urban Local Bodies in India and the Level
of Services Provided, New Delhi.
4. NIUA - 1989 - Upgrading Municipal Services : Norins and Financial Implications, NIUA
Research Studies Series Number 38, New Delhi.
1.
2.
3.
STATE HEALTH EXPENDITURE BY SUBSECTORS
H13V3H AJ-INnwWOD Nl HOHV3S33 303 NOIlVONnOJ 3H1
STATE HEALTH EXPENDITURE BY SUBSECTORS
1976
1971
PUBLIC
HEALTH
1981
FAMILY
WELFARE
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
a MEDICAL
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
PERCENT GROWTH RATE OF MEDICAL
INSTITUTIONS
PERCENT GROWTH RATE OF HOSPITAL/DISP.
BEDS
YEAR
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
GROWTH IN STATE HEALTH EXPENDITURE AS
PERCENT OF ALL GOUT.EXPENDITURE
GROWTH RATE
VEAR
PERCENT GROWTH RATE OF PHC's
60T
1956-61 1961-66 1966-71 1971-76 1976-81 1981-86
YEAR
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
RATE OF REDUCTION IN POPULATION SERVED
PER DOCTOR
ANNUAL RED.RATE
YEAR
ANNUAL RED.RATE
195156
195661
196166
196671
¥EAR
197176
197681
198186
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH
GROWTH IN
STATE HEALTH EXPENDITURE AS
PERCENT OF GNP
GROWTH RATE
(PERCENT)
GROWTH RATE 1.50
1.00
0.50-
0.00-------------- 1--------------------- 1--------------------- 1--------------------- 1--------------------- 1--------------------- (
1951- 1956- 1961- 1966- 1971- 1976- 198156
61
66
71
76
81
86
VEAR
PRIVATE HEALTH SECTOR
Regulation and Control
Prevailing situation
The private health sector consisting of general practitioners,
nursing home and hospital employ two thirds of the medical
manpower and are responsible for two thirds of the
total
expenditure on health in this country.
Despite this there is
hardly any regulation of the practice of this sector of health.
This is indeed surprising because such activity cannot be carried
out without registration.
The medical professional has to be
registered with the Medical Council which is a statutory body that
last set the standards of medical practice,
"discipline" the
professionals,
monitor
their
activities
and
check
any
malpractices.
The doctors who decide to set up their own clinics,
as well as hospitals, nursing homes, polyclinics etc. have to
register with the respective local body.
above is that the controlling bodies are
The reason for this is not only lack of
interest but also weak provisions in the various Acts.
They are
also heavily influenced by the private health sector.
The
problem
with the
virtually non-functional.
Another agent in the private health sector which needs to be
regulated further is the pharmaceutical industry.
As a chemical
industry this agent is regulated to some extent but as a
participant
in
the
health sector
it
operates virtually
unregulated.
In view of the existing health situation and health practices
regulation of those who provide the nation's health care is an
urgent necessity.
Regulation exists in other sectors; so why not
in health; especially as consumer resistance is at its lowest in
this field' and lends easily to malpractice.
How to regulate?
a.
Medical
registered
Practitioners
with
the
;
Each
respective
medical practitioner is
state
Medical Council.
Presently, beyond this registeration the Medical Council does
not concern itself with the practitioner,
unless
some
cornplaint is made and a prima-facie case established.
The
Medical Council, and other related bodies in consultation
with the health ministry must regulate the following areas of
medical practice ■ (This is only a selective list)
i.
Monitoring that only registered practitioners practice
medicine.
ii.
Assuring that clinics have minimum standards of quality
by setting standards for the same (This should include
X-ray, CT Scan & pathology laboratories).
iii. Making maintenance of patient records compulsory and
accessible to the patients.
iv.
Auditing of prescriptions of the doctors in relation to
diagnosis.
v.
Determining a fixed tariff of charges that patients pay
to doctors.
vi.
Providing continuing medical education to all those who
practice medicine.
For instance a
"summer" refresher
course every three to five years should be compulsory
for all practitioners and their license renewal should
be dependent on this.
vii. Regulation of geographical distribution of setting up
practice to correct the urban-rural disparities (we feel
that as of present there is adequate medical humanpower
in the country and it only needs redistribution).
viii.Annual return of patients treated - some minimum data to
be maintained and filed to an appropriate authority.
b.
Nursing Homes and Hospitals : Similar to the practitioner,
regulations need to be made for setting up and running of
hospitals and nursing homes.
Minimum quality standards,
nurse : doctors ratio, patient : nurse ratio, proper location
of premises,
geographical distribution,
fixed reasonable
tarrif charges, proper medical records,
maintenance, filing
of minimum data returns,
properly qualified and adequately
trained personnel for jobs assigned,
prescription auditing,
medical auditing etc.
c.
Pharmaceutical Industry :
i.
The
pharmaceutical
industry
must be
allowed to
manufacture only rational drugs in required amounts with
clear priorities in favour of essential drugs.
All
irrational,
non-essential and dangerous drugs must be
banned.
ii.
Branding of drugs must be prohibited.
iii. There is every reason for a progressive nationalisation
of the pharmaceutical industry.
iv,
The regulating body for the pharmaceutical industry must
be the Health Ministry and not the Chemicals Ministry.
v.
The practice of canvassing drugs through pharmaceutical
(Medical) representatives should be banned.
vi. A National Formulary should be evolved and with generic
drug names must become the basis of
prescription
writing.
vii. Continuing pharmacological education of doctors should
be through MMC or other such statutory body.
d.
General regulation :
i.
To
prevent
unnecessary
concentration
in
urban,
especially metropolitan areas;
state subsidies,
soft
loans etc. must not be given to those willing to set up
practice or hospitals and nursing homes in these areas.
Such loans etc. should be restricted to rural areas and
taluka towns.
ii. A tax on private medical practice and private hospitals
and nursing homes must be levied. This tax should be
the highest in metropolitan areas and lowest in rural
areas.
Private Hospitals should not be allowed to be
operated as Trusts or societies which give them cover
for tax relief.
They should be treated as corporate
bodies.
Hospitals operating 'research centres' must be
audited and their tax reliefs questioned.
iii. A social audit of the health sector must be an ongoing
activity of a statutory body which should be created for
this purpose.
iv.
A tax on international migration of doctors.
v.
Embargo on private practice of those receiving State
Financed Medical Education or high fees/tax for those
who want to practice privately.
vi. Decentralising Medical Education by part training at
civil/rural hospitals and PHCs.
This should be combined
with a long term change of relocating medical colleges
at the district centres.
PREFACE
Collection of data and its analysis to provide necessary evidence for assessing the extent of development of national health
systems and their performance at national and/or sub-national levels has been the major role of any health information system. To
provide timely feedback and appropriate data to programme managers for action has been a challenging task for the health
information team at all levels of the health system. Health intelligence, and not merely health data/information as such, is
increasingly being seen as the lifeblood of any health system by health plannersand policymakers. There is thus a growing demand
for this health information. It is with this in mind that the Regional Office for South-East Asia has taken the initiative to
disseminate Quantitative evidence through this brochure on basic health indicators. Data on health and health-related indicators
of the UN Millennium Development Goals have also been provided.
The data provided in the brochure have been compiled from several sources, including national health information bulletins
and other national publications as well as official publications of WHO and other UN agencies. Data provided by technical units
in the Regional Office have also been used. These data have been verified and validated by concerned focal points in the health
ministries of the Member countries. All efforts have been made to collect and present comparable data from Member countries
for each specified time period.
Wherever possible, the latest available information for individual countries (as of 2000 and 2001) has been presented. Since
these data are subject to many limitations, including fragmentation, non-comparability due to difference in definitions, concepts
and measurement units, as well as inconsistency, caution should be exercised when using the data for trend analysis or intercountry
comparisons. Caution in the use of maternal health indicators is especially important since these data often have varying
definitions, are based on limited survey findings, or are subject to other limitations.
Footnotes for data in the tables are indicated by a superscript alphabetic character either following the indicator title or
following the data value of the indicator for a particular country. The footnotes include explanatory notes regarding major
discrepancies with other official sources, where referenceyears differ from theyear or period shown, where definitions differ, how
data values were calculated, or where other primary sources of data have been cited. The list of footnotes is provided below the
data tables. Sources for the data in the tables are indicated by a superscript number either following the indicator title or
following the data value of the indicator for a particular country. A reference list of data sources and
definitions for the
indicators are also provided below and at the end of the tables. Where data are not available "n/a" has been indicated.
This brochure provides Quantitative evidence. For in-depth epidemiological analysis, assessment of time trends and cross
comparison of data, readers may refer to the WHO/SEARO publication — Health Situation in the South-East Asia Region.
It is hoped that the brochure would help in sensitizing and prompting health functionaries at all levels to collect, analyze and
disseminate timely and consistently reliable health information for all those who need it.
Dr Uton Muchtar Rafei
F.j ;?nal Director
Demographic indicators
Socioeconomic Indicators
—
Indicator
Year
Bangla
-desh
Bhutan
DPR
Korea
Total population
(thousands)'*
2002
143,364
805*"
22,586
Surface area
(thousands of sq km)2
2000
144
47
121
piMion density
(perse, km)'"
2002
Population growth
rate (%)'■“
2000-2005
Crude birth rate
(per 1000 population)'"
2000-2005
Crude death rate (per 1000
population)'"
2000-2005
Urban population
(%)’
Average annual growth
rate of the urban
population (%)3"
17
996
2.09
2.55'2"
34.0912-b
29.9
8.64,2-b
8.7
Indo
nesia
Mal
dives
Myan
mar
Nepal
Sri
Lanka
Thailand
TimorLeste
370
640
n/ah
460
680
2,040
n/ah
250
830
1,970
478"*
2000-2001
3.3
4.0
n/a
2.7
1.8
4.5
n/a
3.4
1.0
0.9
n/a
2000-2001
1.1
n/a
n/a
3.7
11.5
0.6
21.1
2.8
14.2
1.7
n/a
Human Development Index (HDI)5
2001
0.502
0.511
n/a
0.590
0.682
0.751
0.549
0.499
0.730
0.768
n/a
Dependency
ratio'*
Total
Old-age(65+)
Young (0-14)
2000
2000
2000
72
5
67
89
8
81
48
9
39
62
8
54
55
7
48
89
7
83
61
7
53
81
7
74
48
9
39
47
8
39
84
Adult literacy rate
(%)•■'
Total
Male
Female
2000
2000
2000
40.0
49.4
30.2
47.3’
61.17
33.6’
100»-k
W
100»*
57.2
68.4
45.4
86.8
91.8
81.9
96.9
97.0
96.8
84.7
88.9
80.5
41.7
59.4
24.0
91.6
94.4
89.0
95.5
97.1
93.9
n/a
n/a
n/a
Gross primary
school enrolment
ratio (%)9
Total
Male
Female
1999/2000 106.11'
1999/2000 107.57*
1999/2000 104.57*
n/a
100.93
n/a
82.00Wp 108.00*°-" 108.88
62.00*°" 101.00’°" 92.39
107.89
109.71
106.00
133.71
133.22
134.23
90.95
91.39
90.51
126.38
140.00
111.74
105.91*
107.39*
104.38*
93.50
95.72
91.24
n/a
n/a
n/a
Gross secondary
school enrolment
ratio (%)9
Total
Male
Female
1999/2000
1999/2000
1999/2000
49.92
54.88
56.23
53.50
42.75
41.36
44.17
34.87*
53.90
62.26
44.86
72.12*
69.85*
74.47*
78.95
n/a
n/a
n/a
Nepal
Sri
Lanka
Thailand
TimorLeste
Indicator
Year
1,041,144 217,534
309
48,956
24,153
19,287
64,344
850"'
Gross national income (GNI)
per capita (USS)*
2001
0.3
677
147
66
513
15
Gross domestic product (GDP)
per capita growth rate (%)*
Average annual change in
consumer price index (%)5
187
0.68
16.7
3,287
317
1.52
23.8
9.9
8.4
24.5
14.512-9
60.2
2000-2005
3.98
5.95
1.62
2.81
j
India
Myan
mar
2000
g
h
i
DPR
Korea
Mal
dives
28.4
FOOTNOTES FOR DATA TABLES
a Medium variant projection of the
population for mid-year 2001
b Data for 2000
c Calculated from total population for 2001
and surface area for 1999 provided in the
source documents
d Medium variant projection of annual
average rate during the period
e Data for 1995-2000
f Data for 2002
Bangla Bhutan
desh
Indo
nesia
India
1,905
114
1.21
20.0
1,030
1.96,3e
20.0’3b
1.16
23.2
164
2.32
34.0
292
0.94
17.3
125
1.14
17.8
58"*
3.93
4.0,3b
11.6
9.9
6.3
6.2
13.2
40.9
27.413 b
27.7
11.9
23.6
21.6
15.0"*
3.57
3.52
2.86
5.07
2.84
2.67
2.21
n
o
Footnote in the source indicates that data
refer to years or period other than 19951999, differ from the standard definition, or
refer to only part of the country
Data for 1999
p
q
Data lor 1995
Data for 1998
r
91.1% (single dose) 4.6% (two doses)
during 1998
Percentage of total government budget
for 2002
s
5
79
25.4
7.1
Data for 1997
Estimated to be low income (S745 or less)
Due to rounding of decimal point, child
plus elderly dependency ratios may not
add up to Total Dependency Ratio
Calculated from adult illiteracy rates
provided in the source document
k Data for 1996
I Data for 1998/1999
m Data for 1995-1999
72
Coverage by NIDS during 2002
As reported by country for 1999
Figures not endorsed by country as
V
official statistics
w Data for 1994-1998
X As reported by country for both male and
female combined for 1999
y For urban/rural areas for 1998
z Data for 2001
aa Data for 1994-1999
t
u
53.73
51.70
55.90
n/a
7.00*°"
2.0010-n
n/a
n/a
n/a
58.91
40.22
ab Computed from data provided in the source
documents for life expectancy by sex
ac Ratio expressed in percentage
ad Data as of 8 March 2002
ae Data based on previous election
af Data refer to latest year available during the
period 1991-2000
ag Data for 1991
ah Data for 1998 children less than 7 years of age
ai Data for 1992
34.92
34.81'
78.06
79.85
aj Data for 1999 for children < 3 years of age
ak Data for 1994
al Data for 1993
am Data for 1989
an For urban/rurai areas for 1990
ao For 1999 (MMR = 23 from VRS,
MMR = 59.6 from surveillance system)
ap Data for 1987
Primary Health Care Coverage Indicators
Health Resources Indicators
Indicator
Year
Bangla
desh
Bhutan
DPR
Korea
India
Indo
nesia
Mal
dives
Myan
mar
Nepal
Sri
Lanka
Thailand
TimorLeste
Indicator
Total expenditure
on health
(as % of GDP)'*
2000
3.8
4.1
2.1
4.9
2.7
7.6
2.2
5.4
3.6
3.7
9.41'8
Infants
immunized (%)”
P'ilic share to
Aw health
expenditure (%)'*
2000
Per capita total health
expenditure
(international dollars)'4
2000
Physicians
per 10,000
population15
2001
Hospital beds
per 10,000
population'5
36.4
90.6
77.3
17.8
23.7
83.4
17.1
29.3
49.0
57.4
Year
Bangla
desh
2001
2001
2001
2001
70.2"
69.1"
90.0"
62.1°
2001
Pregnant
women”
Deliveries”
DPT3
OPV3
BCG
Measles
2001
2.51
3.36
64
1.6"
16.0"
33
29.7P
136.1"
CES OF DATA
1 UN, World Population Prospects, The 2000 Revision, Volume I:
Comprehensive Tables, New York, 2001
2 UN, 2000 Demographic Yearbook, New York, 2002
3 UN, World Urbanization Prospects, The 1999 Revision, New York, 2001
4 World Bank, World Development Report 2003, Oxford University Press,
New York, 2003
5 UNDP, Human Development Report 2003, Oxford University Press,
New York, 2003
6 UNESCO, htlp://www.unesco.org, July 2002 assessment
7 UNESCO, Statistical Yearbook 1999
8 WHO, Regional Office for South-East Asia, Routine and ad hoc reports from
countries to the EHP Unit, New Delhi, 2000
9 UNESCO, http://www.unesco.org, October 2002
10 UNICEF, The State of the World's Children 2003, Oxford University
Press, New York, 2003
71
84
5.25
6.9=
1.1’
6.03°
254
8.4’
17.4"
24
3.0"
6.3"
66
0.54
1.5
120
4.1’
29’
237
3.0"
22.3"
India
Indo
nesia
Mal
dives
Myan
mar
95.0°
88.4°
89.0°
93.0s
95.0°
90.0’
Sri
Lanka
Nepal
Thailand
TimorLeste
58.0”1
84.01 ”
95.0
75.0
88.0°
100.0°
81.0=
94.6°
94.8°
100.0°
88.1°
77.0°
24.2
90.0=
76.3°
93.0
60.1’
35.0°
98.0=
83.4*
n/a
62.3°
97.0
77.5’
13.5°
97.0’
94.5°
n/a
48.2’
66.4’
42.0=
55.1”
38.9s’
71.0°
72.2
n/a
99.9°
n/a
n/a
77.9°
92.6°
72.3’
n/a
88.2°
71.9°
76.5
n/a
n/a
71.5°
89.2’
65.8’
59.0*
61.0'
75.4’
92.7°
96.0°
74.6’
n/a
n/a
n/a
n/a
n/a
99.2°
36.0’
80.7’
18.9’
n/a
86.9°
54.2°
85
n/a
n/a
63.1°
83.6’
23.0*
74.018.0*
72.6’
87.0’
97.7°
37.4°
52.1’
93.0°
79.0°
76.5’
63.9’
34.4’
59.2’
69.1’
41.7°
93.1’
86.8’
98.0=
98.0’
99.5°
99.0°
63.7"
73.0°
4.6'
66.8°
73.4°
94.0°
2001
33.7"
72.0’
100.0°
65.1’
71.9’
2001
21.8°
23.7°
98.6°
42.3’
2001
53.8°
30.7°
67.0’
97.3°
99.2°
96.7°
77.8’
97.5’
73.2"
54.1°
88.0’
n/a
n/a
88.0°
89.0°
88.0°
80.0
80.0
n/a
n/a
n/a
Pregnant women
immunized with
tetanus toxoid (%)15
47
DPR
Korea
Bhutan
n/a
n/a
n/a
Attended
by trained
personnel:
(% of live births)
Women of child
bearing age using
contraceptives (%)”
Population with
access to safe
water (%)'5
Total
Urban
Rural
2001
2001
2001
Population with
access to
adequate
sanitation (%)15
Total
Urban
Rural
2001
2001
2001
74.6°
49.3°
n/a
n/a
56.5°
59.0*
68.3=
n/a
n/a
n/a
n/a
n/a
11 Timor-Leste, Health Profile, Dili, 26 August 2002
12 Bhutan, Ministry of Health and Education, Report on National Health
Survey 2000
13 Maldives, Statistical Yearbook of Maldives 2001
14 WHO Geneva, The World Health Report 2002, Geneva, 2002
15 WHO, Regional Office for South-East Asia, Health Situation in the SouthEast Asia Region 1998-2000, New Delhi, 2002
17 http://millenniumindicators.un.org/unsd, FAO estimates (3690), July 2003
18 World Bank, http://wwvr.developmentgoals.com, World Development
Indicators Database, April 2002
21 http.7/millenniumindicators.un.org/unsd, UNICEF [29998], July 2003
22 http://millenniumindicators.un.org/unsd, UNICEF [29997], July 2003
23 http://millenniumindicators.un.org/unsd , WHO [29982], April 2003
24 http://millenniumindicators.un.org/unsd, WHO [30002], April 2003
25 http://millenniumindicators.un.org/unsd , WHO [29983], July 2003
26 http://millenniummdicators.un.org/unsd. WHO-UNICEF [27910], April 2003
27 http://millenniumindicators.un.org/unsd, WHO-UNICEF [27920], April 2003
28 http://millenniumindicators.un.org/unsd, WHO estimates [29986], July 2003
19 http://millenniumindicators.un.org/unsd, WHO [29996], July 2003
20 http://millenniumindicators.un.org/unsd, WHO [30001], July 2003
29 http://millenniumindicators.un.org/unsd , WHO [30026], July 2003
30 http://millenniumindicators.un.org/unsd, WHO [30020], April 2003
16 WHO, Regional Office for South-East Asia, country reported HFA data
set 1997
31 http://millenniumindicators.un.org/unsd, UNAIDS (30008], April 2003
32 http://millenniummdicators.un.org/unsd, UNAIDS [30017], April 2003
33 http://millenniummdicators.un org/unsd, UNAIDS [29987], April 2003
34 WHO Geneva, The World Health Report 2003 (draft) Annex tables and
MDG data set (draft), June 2003
35 Myanmar, Health in Myanmar 2002
36 Nepal, Demographic and Health Survey 2001
37 Country Presentations at the Consultative Meeting on MDG Dataset. June
2003, WHO/SEARO, New Delhi
38 http://millenniumindicators.un.org/unsd. UNAIDS [30008], July 2003
39 WHO Geneva, Global Tuberculosis Control, WHO Report 2003
Gender Equity Indicators
Health Status Indicators
Indicator
Life expectancy at
birth (years)34:
Healthy life
c £tancy (HALE)
aWn (years)34:
Total
Male
Female
Total
Male
Female
Infant mortality rate
(per 1000 live births)15
Under-five mortality
rate (per 1000 live
births)34:
Year
Bangla
desh
Bhutan
2002
2002
2002
62.6
62.6
62.6
61.3
60.2
62.4
DPR
Korea
65.8
64.4
67.1
India
61.0
60.1
62.0
Indo
nesia
Mal
dives
Myan
mar
66.4
64.6
64.5
62.3’3"
60.7’51
65.0
63.9’5-1
64.9
67.9
60.1
59.9
60.2
70.3
67.2
74.3
100.8
105.3
98.8
111.3
109.9
n/a
Gender-related development
index (GDI)5
2001
0.495
n/a
n/a
0.574
0.677
n/a
n/a
0.479
0.726
0.766
n/a
21.5
70-95”-’
Ratio of earned income
(females as % of males)5-4"
2001
56
n/a
n/a
n/a
n/a
n/a
n/a
n/a
50
61
n/a
9.3
8.0
6.0
n/a
7.9“
4.4
9.6
n/a
20
16
32
2.0
n/a
81
87
Seats held in parliament
(% women)5ad
9.3
78’5>
78’5->
142
2001
38
43
26
108
Professional and technical
workers (% women)5-41
2001
25
n/a
n/a
n/a
n/a
40
n/a
n/a
49
55
n/a
Adult literacy ratio
(females as a % of males)541
2000
61.1
55.0
100.0
66.4
89.2
99.8
90.6
40.4
94.3
96.7
n/a
Primary school
enrolment ratio (females
as a % of males)9-4'’
1999/2000
97.2
75.6
93.5
84.9
96.6
100.8
99.0
79.8
97.2
95.3
n/a
Secondary school
enrolment ratio (females
as a % of males)9-41
1999/2000
108.1
28.6
n/a
68.3
95.1
106.8
99.7
72.1
106.6
102.3
n/a
2001
Maternal mortality ratio
(per 100,000 live births)15
2000
Low birth weight
newborns (%)’s
2000
19.5
15.1°
9.0s
23.0P
7.7s
17.6'
15.0
23.23
16.7
2000
47.7“
18.7’
60.6n
47.0°
20.3"
30.0-
35.5
47.1°
29.4
5.5
100
g
Data for 1997
h
i
Estimated to be low income (S745 or less)
Due to rounding of decimal point, child
plus elderly dependency ratios may not
add up to Total Dependency Ratio
j
m Data for 1995-1999
104.7
15.4°
Total fertility rate
(per woman)14
Data for 2002
102.8
64.2
45
36
f
106.7
59.8"
87
95
Data for 1998/1999
103.6
21.0=
56
54
I
99.7
S
93
92
k
2001
0.457
71
e
Life expectancy at birth ratio
(females as a % of males)’4-41
0.272
2002
2002
Medium variant projection of annual
average rate during the penod
Data for 1995-2000
57.5
54.8
60.5
n/a
3.0
100/180/
4.6
415'
for-age (%)15
d
TimorLeste
n/a
41.4°
Calculated from adult illiteracy rates
provided in the source document
Data for 1996
Thailand
n/a
68.0*
FOOTNOTES FOR DATA TABLES
a Medium variant projection of the
population for mid-year 2001
b Data for 2000
c Calculated from total population for 2001
and surface area for 1999 provided in the
source documents
Sri
Lanka
n/a
21.8°
iil^en with low weight-
Nepal
n/a
60.5b
373"
Myan
mar
n/a
51.01
407°
Mal
dives
n/a
2001
105“
Indo
nesia
0.218
56.3
258
India
2001
51.6'
49.9'
230
DPR
Korea
Gender empowerment
measure (GEM)5
56.8
57.4
2.4
Bhutan
47.9
51.8
58.2
57.4
58.9
3.1
Bangla
desh
53.5-
53.3
53.6
2.1
Year
49.7
53.4
5.2
Indicator
57.7
62.5
58.9
58.0
59.7
3.6
69.3
66.0
72.7
TimorLeste
60.0
52.9
52.9
52.9
51.8
Thailand
61.3
59.2
64.0
54.3
55.3
53.3
73
Sri
Lanka
52.5
51.1
2002
2002
2002
Male
Female
Nepal
2.1
59.6"
2.0
13.2
8.1"
11.3’
n/a
800”-’
n/a
45.0”-1
o
Footnote in the source indicates that data
refer to years or period other than 19951999, differ from the standard definition, or
refer to only part of the country
Data for 1999
p
q
Data for 1995
Data for 1998
r
91.1% (single dose) 4.6% (two doses)
during 1998
Percentage of total government budget
for 2002
n
s
t
u
v
Coverage by NIDS during 2002
As reported by country for 1999
Figures not endorsed by country as
official statistics
w Data for 1994-1998
x As reported by country for both male and
female combined for 1999
y For urban/rural areas for 1998
z Data for 2001
aa Data for 1994-1999
w
ab Computed from data provided in the
source documents for life expectancy by
sex
ac Ratio expressed in percentage
ad Data as of 8 March 2002
ae Data based on previous election
af Data refer to latest year available during
the period 1991-2000
ag Data for 1991
ah Data for 1998 children less than 7 years
of age
ai
Data for 1992
aj Data for 1999 for children < 3 years of age
ak Data for 1994
al Data for 1993
am Data for 1989
an For urban/rural areas for 1990
ao For 1999 (MMR = 23 from VRS,
MMR = 59.6 from surveillance system)
ap Data for 1987
Health-Related Millennium Development Goals
Health-Related Millennium Development Goals
Indicator
Year
Bangla
desh
Bhutan
DPR
„
Korea
Indo.
nesia
, ..
ncia
Mai..
dives
Myan3
mar
.
Nepal
r
Sri
Lanka
Thailand
TimorLeste
Indicator
Year
Bangla
desh
Bhutan
DPR
Korea
Goal (G) Target (T) Indicator (I)
Goal 6 : COMBAT HIV/AIOS, MALARIA AND OTHER DISEASES
Goal 1 : ERADICATE EXTREME POV ERTY AND HUNGER
Target 7: Have halted by 2015, and begun to reverse, the spread of HIV/AIDS
Target 2: Halve, between 1990 a:id 2015, the proportion of people who suffer from hunger
G6.T7.I18 —HIV prevalence
among young people
G1.T2.I4 —Prevalence of
underweight children
(under-five years of age)
■ W.T2.I5 — Proportion (%)
of population below
minimum level of dietary
energy consumption (w-5*
199O’B
2001’5
54.0’9
47.7°
39.7‘
18.7°
5.027.9*
53.4»
47.0*
41.7*
24,6*=
n/a
30.0
32.4
35.5b
46.9’
48.3*
37.6”
29.4b
20.8’9
11.39
n/a
45.0" =
199117
1999’7
35
35
n/a
n/a
18
34
25
- 24
9
6
n/a
n/a
10
6
19
19
29
23
28
18
n/a
n/a
G4.T5.I14 — Infant mortality rate
G4.T5.I15 — Proportion (%)
of 1 year-old children
immunized for measles
1990’5
2002*
1990’6
136.0’8
72.3
96.9*
84.0’5b
23.0'
90.0’3
112.0’3
90.9
84.0*
51.4W»
48.0
30.0
130.0’8
78.0°
165.0
91.01
22.6ao
18.3
42.0’9
31.4°
92.0’9
51.0
70.7*
14.1“
80.0"
60.0*
34.0
100.0"
102.0
19.3
2000’5
60.5
21.8
68.0"-
40.9"
21.0
59.8”
64.2'
15.4<»
32.8’9
21.5’
199015
2001*
53.0*9
76.0
69.0«r
76.0
99.7P
32.7*
90.3=
85.0
71.0*
65.0’s
86.0*
58.1am
34.0
56.0
93.9"
99.0
73.0
71.0
99.0
94.0
n/a
125.0" =
Mal
dives
Myan
mar
Nepal
Sri
Lanka
t
Thailand
TimorLeste
n/a
n/a
n/a
n/a
n/a
n/a
n/a
0.17
0.18
n/a
0.02
0 03
n/a
0.88
1.32
n/a
n/a
0.01
0.01
n/a
n/a
n/a
n/a
n/a
n/a
n/a
0.22
0.46
n/a
0.05
0.05
15-49 years age group
200138
<0.1
<0.1
0.3*'
0.8
0.1
0.1
1.3"/
0.5
<0.1
1.7"/
n/a
G6.T7.I19 — Condom use in
high risk population<='Drr19>
1990
200132 (M)
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
51.2
n/a
n/a
n/a
n/a
n/a
44.49
n/a
39.8
n/a
n/a
n/a
200132 (F)
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1990
200133
n/a
n/a
n/a
n/a
18,000
n/a
n/a
n/a
n/a
n/a
13.000
n/a
2,000
n/a
290,000
n/a
n/a
n/a
n/a
n/a
2,100
Target 5: Reduce by two-thirds, tsetween 1990 and 2015, the under-five mortality rate
G4.T5.I13 — Under-five mortality
rate (probability of dying
between birth and age 5)
Indo
nesia
1990
200131 (M)
200131 (F)
15-24 years age grouptw8'
Goal 4 : REDUCE CHILD MORTALITY
India
G6.T7.I20 — Ratio of children
orphaned/non-orphaned
in schools<”“val>
Target 8: Have halted by 2015, and begun to reverse the incidence of malaria and other major diseases
n/a
n/a
G6.T8.I21,-Malaria death rate
per 100,000 in children
(0-4 years of age)
1990
200020
n/a
1
n/a
G6.T8.l21b-Malaria death rate
per 100,000 (all ages)
1990
2002"
n/a
G6.T8.l21c—Malaria prevalence
rate per 100,000 Irw3")
1990
2002"
n/a
34
7.5
n/a
0
n/a
6
n/a
0
n/a
n/a
3
n/a
11
n/a
4
n/a
n/a
n/a
9
n/a
n/a
11.4
n/a
n/a
2.9
n/a
n/a
14.6
n/a
17.7
n/a
n/a
3.2
n/a
n/a
n/a
0.0
5.5
6.4
n/a
n/a
19
n/a
14
n/a
n/a
n/a
22
n/a
78
n/a
n/a
57
49
8
Wwget 6: Reduce by three-quarters», between 1990 and 2015, the maternal mortality ratio
G5.T6.I17 — Proportion (%)
of births attended by
skilled health personnel
1990"
470^
380*'
n/a
420=
425*
500
100/190*
850*1
42’9
36.0
n/a
2001"
230b
255"
105"
407"
373’
100=
255150
415
59.6’°
13.2=
800'"
1990"
14.0*
21.8=
15.1*
23.7b
n/a
98.6=
89/36*
42.3"
31.7*
64.8"
95.0’
97.0
n/a
77.5=
9.0>
10.9*
85.2“
97.0=
84.8
2001"
94.5°
n/a
n/a
6
UNESCO, http://www.unesco.org, July 2002 assessment
7
UNESCO, Statisticaf Yearbook 1999
8
SOURCES OF DATA
1
UN, World Population Prospects. Tihe 2000 Revision, Volume 1:
Comprehensive Tables, New York, 2001
4
World Bank, World Development Report 2003, Oxford University Press,
New York, 2003
2
UN, 2000 Demographic Yearbook, IMew York, 2002
UN, World Urbanization Prospects, The 1999 Revision, New York. 2001
5
UNDP, Human Development Report 2003, Oxford University Press.
New York, 2003
3
n/a
n/a
70-95"'
>^al 5 : IMPROVE MATERNAL HEALTI
G5.T6.I16 — Maternal
mortality ratio
n/a
44
WHO, Regional Office for South-East Asia, Routine and ad hoc reports
from countries Io lhe EHP Unit, New Delhi, 2000
9 UNESCO, http:// www.unesco.org, October 2002
10 UNICEF, The State of the World's Children 2003, Oxford University
Press, New York, 2003
11 Timor-Leste, Health Profile, Dili, 26 August 2002
n/a
15
e
n/a
22
12 Bhutan, Ministry of Health and Education. Report on National Health
Survey 2000
13 Maldives, Statisticaf Yearbook of Maldives 2001
14 WHO Geneva. The World Health Report 2002. Geneva. 2002
15 WHO. Regional Office for South-East Asia, Health Situation in the SouthEast As t Repdn 1999-2300. New Delhi, 2002
16 WHO .
set 199.
data
Health-Related Millennium Development Goals
hdicator
Year
Bangla. \
desh
D, ,
Bhutan
DPR
Korea
.
India
Indonesia
Ma ..
dives
Myan1
mar
Nepal
Health-Related Millennium Development Goals
Sri
Lanka
Thailand
TimorLeste
Target 8 (continued)
G6.T8.I22S — Proportion
(%) of population under
age 5 in malaria risk
areas using insecticidetreated bed nets
1990
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
20002’
n/a
n/a
n/a
n/a
0.1
n/a
n/a
n/a
n/a
n/a
n/a
1990
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
200022
n/a
n/a
n/a
n/a
4
n/a
n/a
n/a
n/a
n/a
n/a
G6.T8.l23a — Tuberculosis
death rate per 100,000
1990
2002*
G6.T8.l24a-Proportion
(%) of Smear Positive
Pulmonary Tuberculosis
cases detected and put
under directly observed
treatment short course
(DOTS) «™<r-s«i
G6.T8.l24b—Proportion
-^^) of Smear-Positive
^Ilmonary Tuberculosis
cases detected cured
under directly observed
treatment short course
(DOTS) ip*v*y-2-ao>
v
Year
Bangladesh
D. .
Bhutan
DPR
Korea
India
Indo
nesia
Maidives
Myanmar
r
Sri
Lanka
Tha||and
TimorLeste
Goal 7 : ENSURE ENVIRONMENTAL SUSTAINABILITY
(cJB.I22b— Proportion
V°) of population
under age 5 with
fever being treated
with antimalarial drugs
G6.T8.l23t> - Tuberculosis
prevalence rate per
100,000
Indicator
n/a
54.4
n/a
23.0
n'a
31.8
n/a
40.4
n/a
66.1
n/a
3.5
n/a
33.2
n/a
26.4
n/a
11.4
n/a
18.5
n/a
54.6
1990
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
200255
471
215
343
426
739
48
268
300
116
241
779
1990
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
200129 39
26.3
25.8
56.3
22 7
20.7
88.1
58,6
59.7
74.3
75.1
n/a
1990
20002539
n/a
83
n/a
90
n/a
91
17 http://millenniumindicators.un.org/unsd, FAO estimates (3690), July 2003
18 World Bank, http://wwvr.developmentgoals.com , World Development
Indicators Database, April 2002
19 http://millenniumindicators.un.org/unsd, WHO [29996], July 2003
20 http://millenniumindicators.un.org/unsd, WHO (30001), July 2003
21 http://millenniumindicators.un.org/unsd , UNICEF (29998), July 2003
22 http://millenniumindicators.un.org/unsd , UNICEF [29997], July 2003
23 http://millenniumindicators.un.org/unsd, WHO [29982], April 2003
n/a
84
n/a
87
n/a
95
n/a
82
n/a
86
n/a
77
n/a
69
n/a
n/a
Target 9: Integrate the principles of sustainable development into country policies and programmes and reverse the loss of environmental resources
G7.T9.I29 — Proportion
(%) of population using
biomass fuels
1990
n/a
2000M
969
n/a
n/a
n/a
n/a
n/a
n/a
8TN
63p
n/a
n/a
n/a
n/a
n/a
n/a
n/a
1009
979
89
729
n/a
•
Target 10: Halve, by 2015, the proportion of people without sustainable access to safe drinking water
G7.T10.l30a - Proportion
{%) of population with
sustainable access
to an improved water
source, rural (p10^)
G7.T1O.I3Ob—Proportion
(%) of population with
sustainable access
to an improved water
source, urban (p^^306*
n/a
61
62
n/a
n/a
64
62
78
n/a
60
100
79
69
100
66
87
70
81
n/a
99
n/a
n/a
88
92
n/a
n/a
93
91
87
n/a
99
86
100
95
90
100
89
94
98
95
n/a
199CP6^
93
200026-^
97
199026-3*
200026-34
n/a
Target 11: By 2020 to have achieved a significant improvement in the lives of at least 100 million slum dwellers
G7.T11.131 — Proportion
(%) of urban population
with access to
improved sanitation
199027-3*
81
n/a
n/a
44
66
n/a
n/a
69
94
95
n/a
200027-34
71
65
99
61
69
100
84
73
97
96
n/a
Goal 8 : DEVELOP GLOBAL PARTNERSHIP FOR DEVELOPMENT
Target 17 : In cooperation with pharmaceutical companies, provide access to affordable, essential drugs in developing countries
G8.T17.I46 — Proportion
(%) of population
with access to
affordable essential
drugs on a sustainable
basis ip'0^'*6)
1990
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
199728
80
80
50
80
80
80
50
50
95
80
n/a
24 http://millenniumindicators.un.org/unsd , WHO [30002], April 2003
25 http://millenmumindicators.un.org/unsd , WHO [29983), July 2003
26 http://millenniumindicalors.un.org/unsd, WHO-UNICEF [27910], April 2003
31 http://millenniumindicators.un.org/unsd , UNAIDS [30008], April 2003
36 Nepal, Demographic and Health Survey 2001
27 http://millenniumindicators.un.org/unsd. WHO-UNICEF [27920], April 2003
32 http://millenniumindicators.un.org/unsd , UNAIDS [30017], April 2003
28 http://millenniumindicators.un org/unsd, WHO estimates [29986], July 2003
33 http://millenniumindicators.un.org/unsd, UNAIDS [29987], April 2003
37 Country Presentarions at the Consultative Meeting on MDG Dataset, June
2003, WHO/SEARO, New Delhi
29 http://millenniumindicators.un.org/unsd, WHO [30026], July 2003
30 http://millenniumindicators.un.org/unsd , WHO [30020], April 2003
34 WHO Geneva, The World Health Report 2003 (draft) Annex tables and MDG
data set (draft), June 2003
35 Myanmar, Health in Myanmar 2002
38 http://millenniumindicators.un.org/unsd, UNAIDS [30008], July 2003
39 WHO Geneva, Global Tuberculosis Control, WHO Report 2003
Definitions for Indicators
Adult literacy rate (%): is the percentage of persons aged 15 years and above
who can read and write. The application of this definition is subject to qualifiers
in each country and at each census. (UN, 2000 Demographic Yearbook). Adult
literacy ratio (females as a % of males): is the ratio of adult literacy of females
to that of males, expressed as a percentage. Average annual change in
consumer price index (%): it reflects changes in the cost to the average
consumer of acquiring a basket of goods and services that may be fixed or
changed at specified intervals. (UNDP, Human Development Report 2002).
Average annual growth rate of the urban population (%): is the average
annual rate of change in the percentage of the urban population computed from the
increase in the urban population over five year periods, based on the
odology of the Population Division of the United Nations. (UN, World
Urbanization Prospects, the 1999 Revision). Children with low weight-for
age (%): is the number of children with low weight-for-age as a percentage of the
children weighed. Children whose nutritional status (weight-for-age) is low are
those whose status falls below 80% of the median weight of reference value or
below 2 standard deviations of the national or international reference populations.
such as growth charts of the US National Center for Health Statistics. (UNICEF,
The State of World's Children, 2000). Crude birth rate (per 1000 population):
is the annual number of live births occurring per thousand mid-year population.
(UN, 1993 Demographic Yearbook). Crude death rate (per 1000 population):
is the annual number of deaths occurring per thousand mid-year population. (UN,
2000 Demographic Yearbook). Deliveries attended by trained personnel (%
of live births): is the number of deliveries attended by trained personnel per 100
live births. (WHO, Implementation of Strategies for Health for All by the Year
2000, Third Monitoring of Progress, Common Framework). Gender
Empowerment Measure (GEM): is an index which focuses on three variables
that reflect women's participation in political decision making, their access to
professional opportunities, and lheir earning power (UNDP, Human Development
Report 2003). Gender-related Development Index (GDI): is an adjustment of
®^-luman Development Index (HDI) for gender equity in life expectancy,
3
educational attainment and income. (UNDP, Human Development Report 2003).
Gross Domestic Product (GDP) per capita growth rate (%): is based on
GDP measured in constant prices. Growth in GDP is considered a broad measure
of the growth of an economy. GDP in constant prices can be estimated by
measuring the total quantity of goods and services produced in a period, valuing
prices, and subtracting the cost of intermediate inputs, also in constant prices.
(World Bank, World Development Report 2002). Gross National Income (GNI)
per capita (USS): Formerly Gross National Product or GNP, the broadest measure
of national income, measures total value added from domestic and foreign sources
claimed by residents. GNI comprises Gross Domeslic Product (GDP) plus net
receipts of primary income from foreign sources. Dala are convened from national
currency to current US Dollars using the World Bank Alias Method. This involves
using a 3-year average of exchange rales. (World Bank. World Development
Report 2002). Gross primary school enrolment ratio (%): is the total enrolment
in first-level education, regardless of age, divided by the population of the age-
group which officially corresponds to primary schooling. (UNESCO, World
Education Report 1995). Gross secondary school enrolment ratio (%): is
the total enrolment in second-level education, regardless of age, divided by the
population of the age-group which officially corresponds to secondary schooling.
(UNESCO, World Education Report 1995). Healthy Life Expectancy (HALE)
at birth (years): is the full health life expeclancy al birth. It is the number of years
a newborn child is expected to live in full health during his/her life time subject to
health risks prevailing for a cross section of the population at the lime of his/her
birth. In other words, it is the life expectancy at birth minus the total time expected
to be lost being in ill health. (WHO, The World Health Report 2002). Hospital
beds per 10,000 population: is the ratio of total number of hospital beds
available in the country to the total population, expressed per 10,000 population.
Human Development Index (HDI): is a composite of three indicators which
reflect important dimensions of human development: longevity as measured by
life expectancy at birth; educational attainment as measured by a combination of
adult literacy (two-thirds weight) and combined primary, secondary and tertiary
enrolment ratios (one-third weight), and standard of living as measured by real
GDP per capita (in purchasing power parity dollars). (UNDP. Human Development
Report 2003). Infant mortality rate (per 1000 live births): is the number of
deaths under one year of age per 1000 live births. (WHO, International Statistical
Classification of Diseases and Related Health Problems). Infants immunized
with BCG (%): is the percentage of infants reaching their first birthday that have
been fully immunized (one dose) against tuberculosis. (WHO, Implementation
of Strategies for Health for All by the Year 2000, Third Monitoring of Progress,
Common Framework) Infants immunized with DPT3 (%): is the percentage
of infants reaching their first birthday that have been fully immunized (three doses
according to the immunization scheme adopted in the country) against diphtheria,
tetanus, and whooping cough. (WHO, Implementation of Strategies for Health
for All by the Year 2000, Third Monitoring of Progress. Common Framework).
Infants immunized with measles vaccine (%): is the percentage of infants
reaching their first birthday fully immunized against measles (one dose). (WHO,
Implementation of Strategies for Health for All by the Year 2000, Third Monitoring
of Progress, Common Framework) Infants immunized with OPV3 (%): is the
percentage of infants reaching their first birthday that have been fully immunized
against poliomyelitis (three doses). (WHO, Implementation of Strategies for
Health for All by the Year 2000, Third Monitoring of Progress, Common
Framework). Life expectancy at birth (years): is the number of years newborn
children would live if subject to the mortality risks prevailing for a cross-section
of the population at the time of their birth. (UNICEF, The State of the World's
Children 2003). Life expectancy at birth ratio (females as a % of males): is
the ratio of the life expectancy at birth of females to that of males, expressed as
a percentage. Low birth weight newborns (%): is the number of liveborn
babies with birth weight less than 2500 grams as a percentage of the total number
of liveborn babies weighed, with the measurement being laken preferably within
the first hours of life, before significant postnatal weight loss has occurred. (WHO,
Implementation of Strategies for Health for All by the Year 2000, Third Monitoring
of Progress, Common Framework). Maternal mortality ratio (per 100,000
live births): is fhe number of maternal deaths per 100,000 live births; may also
be expressed per 1000 or 10,000 live births. A maternal death is the death of a
woman while pregnant or within 42 days of termination of pregnancy, from any
cause related to or aggravated by the pregnancy or its management, but not from
accidental or incidental causes. (WHO, International Statistical Classification of
Diseases and Related Health Problems). Old-age dependency ratio: is the
ratio of persons 65 years and above to those in the "economically productive”
age group (15-64 years), i.e. the number of persons 65 years and above per 100
persons between 15 and 64 years. Per capita total health expenditure
(international dollars): is the average amount in international dollars spent per
person on health in the country. Physicians per 10,000 population: is the ratio
of total number of physicians working in the country to the total population,
expressed per 10,000 population. Population density (per sq km): is the
number of persons in the total population for a given year per square kilometer of
total surface area (UN, 2000 Demographic Yearbook) Population growth
rate (%): is computed by taking into account the crude birth rate, the crude death
rate, and the net international migration rate of a country for a given year. (Rates
have been computed as average annual rates of population growth over periods
of five years). It is an algebraic sum of the natural growth rate (crude birth rate
minus crude death rate) and the net international migration rate, expressed as a
percentage. (UN, World Population Prospects, The 2000 Revision). Population
with access to adequate sanitation (%): is the percentage of fhe population
with adequate excreta-disposal facilities that can effectively prevent human,
animal and insect contact with excreta. (WHO, The World Health Report 1996).
Population with access to safe water (%): is the percentage of the population
with safe drinking-water available in the home or with reasonable access to
treated surface waters and untreated but uncontaminated water such as that from
protected boreholes, springs and sanitary wells. (WHO, The World Health Report
1996). Pregnant women attended by trained personnel (% of live births):
is the number cf pregnant women cared for during pregnancy by personnel
trained for pregnancy and childbirth per 100 live births. (WHO, Implementation of
Strategies for Health for All by the Year 2000, Third Monitoring of Progress.
Common Framework). Pregnant women immunized with tetanus toxoid
(%): is the number of pregnant women immunized with two or more doses of
tetanus toxoid per 100 live births. (WHO, Implementation of Strategies for Health
for All by the Year 2000, Third Monitoring of Progress, Common Framework).
Primary school enrolment ratio (females as a % of males): is the ratio of the
primary school enrolment ratio of females to the primary school enrolment ratio of
males, expressed as a percentage Professional and technical workers (%
women): women's share ol positions defined according to the International
Standard Classification of Occupations (ISCO-88) to include physical, mathematical
and engineering science professionals (and associate professionals), life science
and health professionals (and associate professionals), teaching professionals
(and associate professionals) and other professionals and associate professionals.
(UNDP, Human Development Report 2002). Public share to total health
expenditure (%): is the proportion of government expenditure on health to the
total health expenditure. Ratio of earned income (females as % of males): is
the ratio of estimated female earned income to estimated male earned income,
expressed as a percentage (UNDP. Human Development Report 2002). Seats
held in parliament (% women): is the proportion of parliament seats held by
women to those held by men. Secondary school enrolment ratio (females
as a % of males): is the ratio of the secondary school enrolment ratio of females
to the secondary school enrolment ratio of males, expressed as a percentage.
Surface area (thousands of sq km): refers to the total surface area, comprising
land area and inland waters (assumed to consist of major rivers and lakes) and
excluding only polar regions and uninhabited islands. (UN, 2000 Demographic
Yearbook). Total dependency ratio: is the ratio of persons in the "dependent"
ages (under 15 years plus 65 years and above) to those in the ■economically
productive" age group (15-64 years), i.e. the number of persons under 15 years
plus those 65 years and above per 100 persons between 15 and 64 years, A)
expenditure on health (as % of GDP): is the ratio of total expenditure on health
from all sources to the gross domestic product of the country, expressed in
percentage. Total fertility rate (per woman): represents the number of children
that would be bom Io a woman if she were to live to the end of her childbearing
years and bear children at each age in accordance with prevailing age-specific
fertility rates. (UNICEF. The State of the World's Children 1996). Total population
(thousands): is the mid-year estimate of the total population of a country or area
as prepared by the Population Division of the United Nations based on their
methodology for estimations and projections to provide a consistent senes of
demographic parameters for every country of the world. (UN, World Population
Prospects, The 1994 Revision). Under-five mortality rate (per 1000 live
births): is the number of deaths of children under five years of age per 1000 live
births. (WHO. The World Health Report 1996). Urban population (%): is the
percentage of persons living in urban areas. Urban is defined according to
national census definitions The definitions for countnes of the South-East Asia
Region are presented below. Bangladesh: Places having a municipality
(pourashava), a town committee (shahar committee) or a cantonment board.
India: Towns (places with municipal corporation, municipal area committee.
town committee, notified area committee or cantonment board); also, all plj£
having 5000 or more inhabitants, a density of not less than 1000 persons^?'
square mile or 390 per square kilometer, pronounced urban characteristics and
at least three-fourths of the adult male population employed in pursuits other than
agriculture. Indonesia: Municipalities, regency capitals and other places with
urban characteristics Maldives. Male, the capital. Nepat Localities of 9000 or
more inhabitants. Sri Lanka: Municipalities, urban councils and towns. Thailand.
Municipal areas. For Bhutan. DPR Korea, and Myanmar. no definition of "urban"
is available. (UN, Demographic Yearbook, 1988 and 1993). Women of
childbearing age using contraceptives (%): is the number of women of
childbearing age (defined as ages 15-49 years) using contraceptives per 100
women of this age group. (WHO, Implementation of Strategies for Health for Ail
by the Year 2000, Third Monitoring ol Progress, Common Framework). Young
dependency ratio: is the ratio of children under 15 years to those in the
“economically productive" age group (15-64 years), i.e. the number of persons
under 15 years per 100 persons between 15 and 64 years.
MDG Indicators: Concepts and Definitions1
Prevalence of Underweight Children (under-five years of age) (G1.T2.I4):
Proportion of Children of under-five years with low weight-for-age as measured
by percentage of children in moderate and severe malnutrition - those falling
below 80% of the median weight for reference value or below 2 standard
deviations of national or international reference populations, such as growth
charts of the US National Center for Health Statistics. (UNICEF). Proportion (%)
of population below minimum level of dietary energy consumption
(G1.T2.l5f Since there is no specific data available, proxy indicator ‘Proportion
of population undernourished' is used. It is the proportion in percentage of
persons whose food intake falls below the minimum requirement or food intake
that is insufficient to meet dietary energy requirements continuously. (FAO).
Under-five mortality rate (G4.T5.I13): Probability of dying between birth and
exactly live years of age, expressed per 1.000 live births (WHO). Infant
m'^ty rate (G4.T5.I14): Probability of dying between birth and exactly one
yearoi age expressed per 1.000 live births. (WHO. 1CD-10). Proportion (%) of
1 year old children immunized for measles (G4.T5.I15): The percentage of
infants reaching their first birthday fully immunized against measles (1 dose).
(WHO) Maternal mortality ratio (G5.T6.I16): Annual number of maternal
deaths per 100.000 live-births A maternal death is the death of a woman while
pregnant or within 42 days of termination of pregnancy, from any cause related
to or aggravated by the pregnancy or its management, but not from accidental or
incidental causes. (WHO, ICD-10). Proportion (%) of births attended by
skilled health persons: (G5.T6.I17): The proportion in percentage of births
attended by skilled personnel per 100 live-births. Skilled health personnel refer
exclusively to those health personnel (for example, doctors, nurses, midwives)
who have been trained to proficiency in the skills necessary to manage normal
deliveries and diagnose or refer obsletnc complications. Traditional birth attendants
trained or untrained are not included in this category. (WHO). HIV prevalence
among young people (G6.T7.I18): Since the relevant data is not available, the
proxy indicator as proposed by UNAIDS/WHO is used. The proxy indicator is
’HIV prevalence among 15-24 years old by sex" which is the estimated
number ol young people (15-24 years old) living with HIV/AIDS as per proportion
of the same population and sex. These country-specific estimates are expressed
as a range generated by regional modeling (UNAIDS). The other proxy indicator
is ’HIV prevalence rate among population 15-49 years of age". Condom
u:^ high-risk population (G6.T7.I19)-. Since the data is not available, it has
be^roposed to use ‘condom-use among 15-24 years old by sex ". This is
the percentage of young men and women of age 15-24 years, who said that they
used a condom the last time they had sex with a non-marital, non-cohabiting
partner, ol those who have had sex with such a partner in the last 12 months
(UNICEF/UNAIDS). Raffo of children orphaned/non-orphaned in schools
(G6.T7.I2O): Since the data is not available, proxy indicator is used as ‘AIDS
orphans currently living’which is the estimated number of children (0-14) in
a given year, having lost their mother or both parents to AIDS. (UNAIDS)
Malaria death rate per 100,000 in children (0-4 years of age) (G6.T8.I21.):
Proportion of children (0-4 years of age) died due to malaria in a given year.
(WHO). Malaria death rate per 100,000 In all age groups (G6.T8.l2h,)'
Proportion of people of all age groups died due to malaria in a given year (WHO).
It is malaria crude death rate. Malaria prevalence rate per 100,000 population
(G6.T8.l2h): Proportion of notified or reported cases of malaria per 100,000
population in a given year (WHO). It is malaria crude prevalence rate. Proportion
(*>) of population under age 5 in malaria risk areas using insecticide
treated bed nets (G6.T8.I22,) The percentage of children under-five years of
age who are using insecticide-treated bed nets among the same population living
in malaria risk area, in a given year. (UNICEF/WHO). Proportion (%) of
population under age 5 with fever being treated with anti-malarial drugs
(G6.T8.I22J: The percentage of children under-five years of age who are with
fever being treated with anti-malarial drugs among the same population living in
malaria risk area, in a given year. (UNICEF/WHO). Tuberculosis death rate
per 100,000 (G6.T8.I23,): Proportion of people of all age- groups died due to
tuberculosis in a given year. (WHO). Tuberculosis prevalence rate per 100,000
(G6.T8.I23,,): Proportion of tuberculosis cases of all age-groups per 100,000
population in a given year (WHO). Proportion (%) of smear-positive pulmonary
tuberculosis cases detected and put under directly observed treatment
short-course (DOTS) (G6.T8.I24,): Since the baseline data is not available
WHO proposed to use ‘DOTS detection rate" (WHO). Proportion (%) of smear
positive pulmonary tuberculosis cases detected cured under directly
observed treatment short-course (DOTS) (G6.T8.l24b): Since the baseline
data is not available WHO proposed to use ‘DOTS cure rate" which implies
treatment success rate that is treatment completion rate and cure rate (WHO).
Proportion (%) of population using bio-mass fuel (G7.T9.I29): Bio-mass
fuel is any matenal, derived from plants or animals, deliberately burnt by human,
for example, wood, animal dung, crop residues, and coal. Since the baseline
data is not available the proxy indicator is proposed as “percentage of
populations using solid fuels'. (WHO/UNICEF). Proportion (%) of
population with sustainable access to an improved water source, rural
(G7.T10.I30,): Since the baseline data are not available, the proxy indicator
‘percentage of population with access to improved drinking water sources,
rural' is used, 'improved' water sources mean household connection, public
standpipe, borehole, protected dug well, protected spring, rainwater collection.
'Access' means the availability of at least 20 litres per person per day from a
source within one kilometre of the user’s dwelling. (WHO). Proportion (%) of
population with sustainable access to an improved water source, urban
(G7.T1O.I3Ol:: Since the baseline data are not available, the proxy indicator
percentage of population with access to improved drinking water sources,
urban' is used. “Improved’ water sources mean household connection, public
standpipe, borehole, protected dug well, protected spring, rainwater collection.
"Access" means the availability ol at least 20 litres per person per day from a
source within one kilometre of the user’s dwelling. (WHO) Proportion (%) of
urban population with access to improved sanitation (G7.T11.I31):
“Improved" sanitation means: connection to a public sewer, connection to septic
system, pour-flush latrine, simple pit latrine, or ventilated improved pit latrine. The
excreta disposal system is considered adequate if it is private or shared (but not
public) and il hygienically separates human excreta from human conlact. (WHO).
Proportion (%) of population with access to affordable essential drugs
on a sustainable basis (G8.T17.I46): Since the baseline data is not available,
the proxy indicator ‘percentage of population with access to essential
drugs', which WHO routinely reports for international comparison, is used.
Every year, in order to estimate the level of access to essenlial drugs, WHO
Global Aclion Programme on Essential Drugs interviews relevant experts in each
country about the pharmaceutical situation. The interviewees could choose from
four levels of access by the population to essential drugs: less than 50%;
between 50-80%: 80-95%; and above 95%. They indicate which category is
most appropriate for their country. Essential drugs are those drugs that satisfy the
health care needs of the majority of the population. (WHO).
’ The concepts and definitions reproduced from the original sources (in bracket at
end of each definition).
Health Situation
in South-East Asia
INDICATORS
^2oo;
Includes
Progress Towards
Achieving
Health-Related
United Nations
Millennium
Development
Goals
For more information please contact:
EHP Unit, WHO/SEARO, New Delhi
httpVwww.whosea.org
e-mail: frica@whosea.org
singhn@whosea.org
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