RF_COM_H_60_SUDHA.pdf
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SAR£I, PLAN
Half the population in Sdrai Village is tribal while the
other naif is low caste people. The land around the village
was owned by the tribals earlier but now it belonged to the
•Malik’ in the nearby village and the Sarai villagers were
working for the Malik for the wage of Rs.3/" per day. The
nearest medical facility ’was in the town about 27 km away.
There was no motorable road for 10km to the town. Diarrhoea
deaths during monsoon and famine deaths during lean season
was a common occurance. The children and mothers were highly
anaemic.
It was at the state Fr.Amal came to this village. He
spent sometime with the villagers and came to the conclusion
that something had to be done. He contacted the Sisters of
Charity and explained the condition of the village. Sr.Karuna
in that community was occassionally visiting some villages
near their station. She talked to Sr.Sneha and both of them
decided to work in the village of Sarai and obtained necess
ary permission from their superiors.
Question; What will be your plan of action if you were in
the position of Sr.Karuna and Sr.Sneha?
Mi;19.09.1986:200
Prepare,; |,y
^omr.iur .
V0fa«3rz ■ ,
c-m,
N»» Delhi-;iooi6
CASE STUDY :
Tcanl
Wa
‘'e’SDA.
CHAKRAPUR
Chakrapur is about 20 km fran the project base. It is in a hilly area
and is quite cut off fran ether villages. The people depend cn each other
for survival. Very few of them are literate. Caste feeling is not very
strong in the. village.
45$ of the villagers are Yadavs
25$
"
" Brahmins
20$
"
" Harijans
5$
"
" Kumbhars
5$
"
" Muslims
The people requested the Community Health Project (CHP) to open a health
clinic 2 years ago and gave full cooperation. They provided a place for
the clinic and repaired the road partly through shaimdan, Panchayat's cash
donation and food for work progranme started by the CHP.
Then the project'director decided to train a.V.ill age Health Worker (VHW).
He chose Lakshmi, an intelligent though poor Kumbhar woman.
After the
training Lakshmi was very efficient and'responsible in her work. The
villagers were quite satisfied with her. She was therefore also made
responsible for distributing bulgar and milk in a feeding progranme for
the village children.
a
Sane months later/ Fanners' Club was formed for the '.benefit of all in
the village. The club committee had a representative fran all caste groups.
The project's social worker, was also a member of this committee. He was
supposed to coordinate the different activities of the progranme in the
vi 11 age, though the project director had the ultimate authority.
Recently, the Farmers' Club criticised the VHW1 s work. They felt she was
distributing cnly half the bulgar and suspected she was cheating. They
canplained to the social worker and also told him that the VHW was of
"low moral character". The social worker, who respected both the club members
and the VHW, went to investigate. He found the VHW was actually distri
buting less bulgar and told the project director about this.
After some days the Farmers' Club demanded that the 2 village volunteers
that helped the VHW be replaced by people chosen by the club. The VHW
knew the project director had faith in her. She argued with the club
members that her helpers were already trained in their work and the children
listened to than. She saw no reason to waste time and effort in training
new people.
The matter was left as it was. Two months later the VHW asked all the
parents of children in the feeding programme to pay Rs. 0.25 per month for
the food. She also ordered than, to bring seme salt to be mixed with the
bulgar. The Brahmins and Yadavs of the village were adamant that their
children should not consume Harijan's salt as that amounted to breaking the
'sacred' caste code. They threatened the VHW with dire consequences if she
went ahead with her .proposal. The VHW, secure in her position, ridiculed
them aS 'High Caste Fools'.
She threatened the Brahmins and Yadavs by
saying "I'll see to it that you get no work in the food for work progranme".
Of course she had no authority to say this. A heated discussion followed.
One of the members of the Farmers' Club slapped the VHW.
=xXx=
chttzpt:19.5.’B1
CASE STUDY . < \ ISriALNAGAR
A group of Health Workers were living in a Health Centre one
mile away from Vishalnagar. A landlord of this village req
uested the Health Workers to open a dispensary and agreed to
donate land for the building. The Health Workers opened the
dispensary and had been working there for about six months'
when one day some people from the village threw stones at
them. The Health Workers were at first shocked by this vio
lence. After some days they decided to ask an outside agency
to help them find out what had gene wrong. The group did a
survey of the village and we are giving below some of the
information they found cut s
Vishalnagar has a population of 525 and there are 90 house
holds in the village. The average number of people per house
is 5.8 and the average number of children per house is 2.7.
Economic structure :
Most of the village people depend on agriculture for- their
livelihood. The total acreage under cultivation is about 400
acres.
Land holding pattern ?
farmer
farmer
farmer
1
families
66 families
250 acres
100
"
50
”
some land (less than 2 acreas each
- .landless labourers
-
The land of the landlords is cultivated by tenants but there
is no document to prove the tenancy. These tenants are small
farmers and landless labourers. At harvest time 50% of the
produce goes tc the landlord and the remaining 50% (after
subtracting the price of seeds, fertilizers, electricity bill)
is distributed among the tenants.
Wagc-s
Women are paid Rs.2/- per day
Rs.4/- per day
Men are paid
Other sources of income
There are 36 cows, 16 bullocks and 19 buffaloes in the
Village. Except for 10 animals the- rest of the livestock
belongs to the three landlords. The animals are cared for
by the Harijans for which the Harijans received Rs.3 to
Rs.5 per month as wages.
Credit :
The- landlords arc the main money lenders. There are no co
operatives or banks in the village. The village people take
loans mostly to buy grains when they have no work, for
marraiges and for funerals. They have to repay trie loan
during the harvest season and the amount is cut off from
their wages. The interest rate is between Rs. 10 - Rs.12
per Rs.100 per month. Normally after the loan has been
cut off a labourer gets no more than Rs.15 - 20.
Housing ;
The landlords live in good houses. Most of the Harijans live
in little huts. A few years ago the Government donated some
land tc 30 Harijans to build their houses. As sosme of the
land was cutside the Panchayat’s limit the Harijans were not
2.
able to get finances to build all the houses. Only 15 houses
could be completed. At the time of the survey seven of the 15
houses were in the hands of tne landlords(mortgaged) . The houses
in the possession of the landlords were rented out to the
Harijans for Rs. 10 per month.
Political Structure :
The Panchayat office is situated in the' neighbouring village.
There ar: two panchayat members in Vishainagar. These two mem
bers are the Pvippe-ts of the landlords. After their election to
the Panchayat, they have got the Government grant to dig two
drinking water wells, electricity the village and build the 15
Harijan houses.
Hindus
- 66.2%
Christians
- 33.5%
Muslims
- 0.3%
The whole village celebrates the festivals of different religions
together.
Religious groups ;
Caste structure :
There are 3 main casts in the village:
Reddys
- 25.7%
Harijans
- 37.2%
Vaddas
- 17.4%
Others
- 19.7%
Of these the Reddy are the dominant caste. Untouchability against
the Harijans is still practices. The Harijans are not allowed
to take water from the same well.
Health Status :
The staple diet is ragi, dhal and green vegetables. The rich
landlords have two meals in a day whereas the poor people have
only one. There are no serious illnesses in the last year
except for two cases of Asthma. The motality rate in children
is low. 10% cf the Harijans families had limited their family
size by the birth control operation.
Health Services :
There is no private practitioners in the village. The Government
hospital is about 2 miles a-./ay. The dispensary run by the Health
Workers does nut get more than one or two patients per day. The
Health Workers were giving medicines, grains, mild powder and
clothes to the landlord for distribution among the poor but
these things never reached the poor.
Needs :
When asked what the people needed most, the majority expressed
their wish to have a house cf their own. Some of them are living
in rented houses belonging to the landlords. (If the labourers
fail or- refuse to work in the fields of the landlord, the land
lord w^uld simply lock the houses. The other people are staying
in huts). Another need the village- people expressed was a school.
The peer people also asked to be provided with cattle as there
was no possibility of them acquiring any land. In spite of the
poverty and misery many expressed the desire to build a place
of worship.
Needs in order of people's priority:
1. Houses
2. School
3.
Cattle
4. Temple
5. Bettor wages
CASE STUDY : GUMHL
(T.W.)
Gumri Health Centre had a staff of three trained ATMs, Sindhu, Kamala
and Balana. Balama was the most experienced of the -three having worked in
a good Community Health Programme for three years. She had also attended
a course inCommunity Health and Development. Sindhu i_d Kamala had joined
Gumri immediately after their training 5 years ago. These ANMs decided
to start a Conmunity Health Progranme in the nearby villages. As Balana
was more
experienced, she was naturally chosen as their leader. .
They selected three of the villages
Together they discussed
the objectives cf their programme and how they would go about implementing ' ' ,
it.
They decided to take as target group the under-five children and
the women of child bearing age.
Balama who was aware of the necessity to
have the people involved in the progranme, insisted that they should first
spend time visiting the villages, befriending the people and learning'about
the problems of the canmunities -before starting any specific activity.
The ANMs visited several villages.
where they had been particularly well received.
Sindhu and Kamala did not contradict her, but Sindhu felt strongly that
immunisation and Family Planning progranmes should be started immediately. ■
Sindhu thought, "After all^ don’t we all know that these programmes are a
priority? Then why waste time visiting the villages, and chatting with
the people when we could already start good progranmes?"
K anal a was a
happy, go lucky person and could not care less what she started with. She
was therefore ready to follow Balama all the way.
Still, after their discussion, the following plan of action was decided:
1.
2.
3.
4.
5.
Joint weekly visits to the three villages
Primary level curative service to be started immediately
Intensive visits of the families to be done
Leaders to be identified, 4°°d rapport with the people to be
established, before starting specific progranme
Health progranme to be planned jointly with the people.
Sindhu was amused. "Whoever would think of planning with the people?"
she thought.
So they started their woik. After six months a visitor
helped the health workers to review their activities in order to find out
how things were progressing.
The following observations were made:
1.
The three villages were regularly visited by the three woikers once
a week. During these visits the patients were first seen.'
Then
the woikers visited the families separately. Besides this, Balama
and Kamala very often went together for an extra weekly visit to all
the villages. During that time Sindhu went to the PHO and obtained
from the doctor there, DPT and DT vaccines,
2.
Balana and Kanala took time to visit the fanilies, discussed with the
people and became quite friendly with all. They met the Sarpanch and
several of the important people in the village and discussed with them
the conmunity’s needs. They learot that, in two villages, there was
no drinking water facility and this was a real problem. The drinking
water had to be taken from a pool where buffaloes tocktheir bath.
2/
t
2
3.
Sindhu visited the schools and Balwadi, gathered the children
present there and gave the first dose of DPT and DT'to 450
children.
When the time ewe for the second .dose, only 200
children received the dose (it was the marriage season and many
children did not come to the school).
4.
During another visit, Sindhu had also gathered the wanen to give health education. She expected, through this programme,
to be able to motivate the women for family planning. The first
day all the women came zs they did net know what to expect.
But soon most of the women dropped out of the class.
After two months of the work Sindhu decided that it was a waste of
time to visit the villages so often and so decided to visit cnce
a month only. Balama and. Knnala continued their weekly visit with
the sane enthusiasm.
scxx========
chtti'pt: 19«5,’81
Prepared by
Community Health Team
Voluntary Heaitii Association of India
C-14, Lommani.y Ccmre, S.D.A.
blew Delin-llJ 016.
FIGHTING BACK
It started two months back when five Harijans of Karainchedu
village of Prakasam District in Andhra Pradesh were killed
by the Kamma landlords of the area.
The government refused
to arrest the culprits.
The Harijan MLA ’ s wore reluctant to
raise the problem in the Legislative Assembly.
Upon this, more
than pOO Harijans of Madiga sect moved from Karamchedu even
though the Mala Harijans refused to join them for fear of
unemployment.
The Madiga settled down in Chirala 8 K.M. from Karamchedu.
Under the leadership of Kathi Padma Rao, a Harijan college
lecturer, Karamchedu Victims Relief Committee has been formed.
From Bs,1.20 lakhs they raised as donations from various sources,
they bought 8 acres of land and have started building new homes.
Though they left Karamchedu without money or posessions, their
unity and defiance have helped them to build four thatched huts
and an open community kitchen to servo them rice or gruel twice
a day.
They have definitely clarified that they would not
accept any official help.
They have named the village
Vi j ayanagar.
The Harijan representatives of Andhra Pradesh are using this
personal trajody of the death of five Harijans as a stepping
stone to a social movement which will fight against the opression
of downtrodden in the state.
They mot at Chirala and called for
a'rail aur rastha roko1 agitation on September Sth.
This
agitation disrupted the traffic upto Hyderabad.
The demands
wore that the real culprits who arc related to political
leaders be punished and that the migrated Harijans be permanently
rehabilitated in Vijayanagar.
The Kammas of Karamchedu accuse Padma Rao of trying to gain
political leadership and money from the trajody.
They claim
that before the incident took place, there was close intorcasto relationship between Kammas and the Harijans tc the
extend that both of them were drawing water from the same pond
and that the Killing occured when Kamma youths were assaulted
by Harijans.
....
■ .
(India Today Sept. 30th ’85)
Why did tie Madiga
<• ■
.
1
Why did the Madiga. Harijans of Karamchedu take to this course
of action?
•
■
• i
■
j
What are the features of - this people's action?
What relation do you sec between the responses of the Government
and the Kammas?
i.
Why Harijans and Tribal murders are frequent occurCncos in
India?
What all factors contributed to spreading this-micro (village)
level incident to a macro' (state/national) movement? .
Community Health Department
C.H.A.
C.B.C.I. Centre
Cole dakkhana
New Dolhi-110 001
The Catholic Hospital Association of India
C. B. C. I. Centre, Goldakkhana, New Delhi - 110001
Tel. 310694, 322064
SHpmKKAM^ CASE_STUDY... X.DUPLICA11,ION . 0F„. SERVICES)
A team of health workers, attached to the private health
centre of Shorpakkam, decided to start a community health programme
in an area near their health centre. They knew that they would not
be duplicating Services because the Government Primary Health Centre
was situated more than 20 km. from Shorpakkam, and people visited,
attending Shorpakkam health centre had told them that nobody ever
visited their village.
The health workers of Shorpakkam had good rapport with the
villagers through the dispensary attached to the health centre.
The workers studied their OPD records and found that their patients
were mainly coming from three fairly big villages situated between
two to three km. from Shorpakkam.
The health workers discussed with the patients of the three
villages the possibility of developing community health programmes
in their respective villages. All of them were very keen on this
and repeated that nobody ever came to visit them and help them with
their health problems.
And so the health workers started their programmes in the
three selected villages. They had a weekly dispensary, mother and
child health programme with CRS food supply and house to house
visiting.
During their house to house visit of one of the villages,
the health workers came across a Government AM who was residing
in that particular village for the past one year.
It seems that
the PHC had opened three new sub centres in the past year, and one
of these sub centre was in this particular village. The AM was a
very nice person and seemed to be well accepted by the women of th
village.
chtt/la/1-3-84
Questions :
Prepared by
Voluntary Health Association
of India, C-14 Community
Centre, S• Delhi - 16.
1.
The people of one village misled to the health workers of
Shorpakkam. Why, do you think did the people hid the fact that
there was a govt, sub centre in their village ?
2.
On the base of the peole's word the health workers started a
Community Health Programme. Are there any other steps the
health workers should have taken before choosing the villages?
What steps ?
3.
If you were in the same position than the health workers of
shorpakkam, what you do now ? Explain your answer.
QUESTIONNAIRE
a. Read the list of adjectives given below.
which six adjectives
seem to you „o be the most accurate when describing villagers.
1 .
2.
3.
4.
3•
6.
Shrewd
Analytical
Competent
Generous
Lazy
Shallow
Reliable
Insecure
Mature
Conservative
unco-operative ^motional
Irresponsible Restless
Enthusiastic Frustrated
Money-minded Confused
Unreliable
Dogmatic
Ignorant
Efficient
Stupid
Paternalistic
Kind
Dependent
Sensitive
Powerful
Over-bearing
Weak
Exploited
Backward
Risk-taking
Hard-working
Impulsive
Immature
Naive
Idealistic
Progressive
Apathetic
Uncommunicative Responsible
Helpful
Appreciative
Concerned
Incompetent
Childish
Cautious
Unkind
Independent
Skillful
Supportive
b. From the same list, which six adjectives seem to you to be the
most accurate when describing yourself?
1 .
2.
4.
5.
6.
c. From the same list, which six adjectives do you think would
describe qualities most desirable in a development worker?
1 .
2.
3.
4.
5.
6.
THIRUNELLY - CASE STUDY
Thirunelly is situated in VJynad District of Kerala
State, adjacent to Karnataka boundry, with thick reserve
forests around and it has a population of 2000 people. 90%
of the inhabitants are Adivasis who once enjoyed the
ship of the entire land.
owner
But later, with the invasion of
migrants from other places, the illiterate and simple Tribals
lost all their land and today they own only 10 to 15
cents
of land and a few people have 2-to 3 acres. About 95% of
the people are agricultural labours. The nearest public
health centre is M- km. away from this village, and the
lower primary school in the area has 86 students but only
8 are Adivasis.
There is a temple in Thirunelly, which
attracts pilgrims from all over the country.
Thirunelly comes to limelight and public attention
every year because of mass deaths in the beginning of monsoon,
when there is no work,
People are affected by Diarrhoea
vomiting and fever and quite a number of them succumb to it.
Government named this phenomenon gastro-enterits. In 1977,
13 people died and many groups like Lions Club, Jeycees and
other agencies including the Diocese brought in aid from
outside. Later in 1978 Diocesan Social Service launched
a conscientization programme in their village on a massive
scale.in 1978,
8 people and in 1979, 7 died again.
Questions.
- Why mass-deaths, in Thirunelly?
A
- If you are in this situation what programmes
would you undertake?
COMMUNITY HEALTH DEPARTMENT
CHAI.
.-1ST JOHN'S MEDICAL CCLLEGE
BANGALORE
PARTICIPATION ASSzSSI-ENT (First Step)
1.
Check off the things that you did during today's session.
I listened
I read
I copied down notes
I wrote down my own ideas
■I mentally evaluated
ideas presented by
others
I offered ideas of my
own verbally
I took part in small
group discussion
I took part in \;hole
group discussion
Any other ? Specify .
2.
t
3.
I engaged in problem
solving individually --------in a team
I related theoretical
concepts to my own field
experience
I role-played
I participated in practical
activity
I created or helped create
a (communication) message
I got bored
I fell asleep
which statement best describes the way you feel in a new group ?
I ge nerally•
prefer to sit quietly and listen to others
feel quite at ease taking part in discussion
" find myself ready for some form of leadership role
sometimes wish I could take over and structure the discussion
ease
prefer to listen for a while and then participate after I
have a feel for the group
other
Imagine that you have been approached by a social reformer who
wants you to change sone aspect of _your lifestyle in the interest
of the nation or of the world , or perhaps just '‘for your own
good". You appreciate the new point of view, but are also aware
that any change on your part would involve certain personal
risk and criticism from some of your peers. What would you do?
You may check off more than one box, but if so, rank them by
number.
Take the social reformer ‘s advice and adopt the change right
away.
_____ Wait to see what other people will do.
’
Actively look for other community members who are interested,
'
and form
a study group
__
__ an action group
’Try to lear’n more awout the subject ’wS’thout letting anyone
~~ know? of your interest
ether response (specify)
______________
2
4.
1.
2.
3.
4.
5.
6.
7.
8.
9.
; 2 :
Facing problems
List f. specific problems that you and people in your peer
group often face.
Number them in order of difficulty of solution.
Put an asterisk in front of those that can be solved only
through influential connections.
Put a circle around the ones that require a lot of money to
resolve.
Underline the ones that affect you in particular.
Re-underline the one that would make you most happy if solved.
Against each of the problems that affect you, write the date
when you last did something towards solving them.
Check off tne ones that you have been able to solve
Consider: what does this exercise tell you about your
ability to confront problems ?
prk/191281
HANDLING CONFLICT
1.
Ths ELEMENTS of conflict, as examplified from "The Prisoners'
Dilerma"s
ds ASSUMPTIONS:
They may bo accurate or inaccurate.
1. Accurateg
"The object of this game is to make as-much money
as- possible, without hurting or helping the other".
2.
Inaccurate:
"The object of this game is to beat the' others".
Ss INTENTIONS:
They may be genuine or exploitive.
1. Genuine: "ije must earn money"
2.
Exploitive: "Ije must win".
C. COMMUNICATION:
It may be evaluative (judgemental, accusatory) or merely descrip
tive (direct, non-accusatory); and it may include positive or
.negative feelings.
1.
Evaluative and judgemental: "You crooks can't be trusted!"
2. Descriptive and Direct:
" I am not sure I can trust you"
3.
With negative Feelings:
"You're cheating!" (Anger)
4.
IJith positive feelings:
"Let's both play the blue card" (Trust)
D. BEHAVIOUR:
It may be reactive (against) or proactive (for); rejecting or
accepting; defensive or open.
1. Reactive : "We'll play.the red card!"
2. Proact ive:
"Let's play the blue card."
3.
Rejecting:
"|\|o negotiations with them!"
4.
Accepting;
"Let's give them a chance to prove themselves."
5.
Defensive:
"Be careful!
6.
Open: "Whatever happens, we'll stand by our word."
They are out to trick us!"
TWO POSSI 8LE APPROACHES to resolve a conflict;
A. From the level of Assumptions and Intentions:
ASSUMPTIONS
Accurat e
P
t
Inaccurate
-2-
— To move from Conflict situation to a Problem-solving one,
correct the assumptions and intentions of both sides, (seo Page 3)
g. From the level of Communications and Behaviours
_L_
Reactive
Rejecting
Defensive
(Negative Feelings: "against")
Open
accepting
Proactive
(Positive Feelings: "For")
__ To move from Conflict situation, a move to the right in this
case would be the right one.
PARENT-ADOLESCENT CONFLICT
Sit uation:
an over-protective mother and a rebellious teenager.
not her: "all I want is that my son should be happy and secure."
Son:
"i wish she’d stop talking about my, happiness.
It's she
who makes my life miserable.
Her whining and worrying
and ragging are driving me crazy’."
Assumpt ion;
1. Inaccurat e;
Mother:
Son:
"He needs me to look a ft or him."
"She's out to embarrass me ?nd make my life miserable."'
2. accurate:
Mother:
Son;
"He doesn't like my babying him."
"She's concerned about me."
Intentions:
1.
-
Exploitive:
Mother:
Son:
"He'll do as I think best and like itl"
"I'm going to see that she keeps out of my hair!"
2. Genuine:
Mother:
Son:
"I really want my son to grow up happy."
"I want to prove to her that she need not worry about me".
ASSUMPTIONS
Accurate
I'Uthsr: "He doesn't
like my babying him,
so I have to Tina out
how I can best help
him to be happy and
mat ure" •
Son: "Sho's worried
about me, s) I have
to show her, that she
need not be; that I
can stand on my own
feet".
FRO BL EM-SO LUI NG
Inaccurate
Mother: "He's not old
enough to look after
himself, so I've got
to do what is best to
help him grow up happy".
Son: "Until I can prove
to her that I don't
need her to wipe my
nose; she's going to
drive me crazy.
So
I'd better show her
that I am old enough
to take care of myself."
HELPING APPROACH
TICK'S---------------------------------------"Tit her: "He may not
.Lika it, but he'll do
as I say as long as
he's my son."
Son; "Let her worry'.
I'11 pay her off
against my father.
L'hat she doesn't know
won't hurt her'."
MANIPULATION
Mother: "He is not old
enough to look after
himself, so I intend to
tell him how to behave,
whether he likes it or
notl After all, Mother
knows best I"
Son: "as long as she
keeps nagging me and
embarrassing me in front
of my friends, I'm going
to stay as far away from
her as possible, and do
whatever I please'."
CONFLICT
-2-
III HOUSE RENT
Find out through inquiries what is the minimum rent for a
quarter in a bustee or village per month = Rs.(ill)
IV MISCELLANEOUS
Expenditure for fuel, light, etc. is calculated as 20%
the total monthly income.
(I)
Rs.
- Cloth
(II)
Rs.
- Rent
(HI)
Rs.
- F Jod
TOTAL
= Miscellaneous
Rs. ___________
X 1/4
Rs.___________.(IV)
Therefore, the minimum amount of money needed today to support
a family of four in your area = I + 11 + III
IV = Rs^-...
1.
Extent of inequality in the world todays
a. In 1350, 3/4 of the world's population possessed 5/8 of the
world's wealth.
in 1975, 2/3 of the world's population possessed l/S of the
world's wealth
b.
Whence came this uneven distribution of the world's resources?
"The tilting of tne balance in favour of the West has come about
in the last 130 years .......thro ugh the gun, through colonial plunder,
slave trade, slave labour, child labour, racial discrimination, the
creation of a dispossessed proletariate, and the destruction of the soul
and life-style of many peoples."
(s« Rayan)
c. The growing gap between the rich nations and the poor had
already been pointed out by Barbara Ward in the 1950's but the gap
continues to widen;
"Today 85/ and tomorrow 90/ rot in misery to make possible the
economic comfort of 15% today and 10% tomorrow"
( Heder Camara)
d. The result of this inequality is the ABSOLUTE POVERTY of
millions in the "fourth" world;
- 1/3 to 1/2 of the two billion human beings in Asia, .Africa
and Latin America suffer from hunger and malnutrition.
- 1/5 to 1/4 of their children, die before their fifth birth
day, and millions of those who do survive lead impoded lives, due to
brain damage, stunted physical growth and sapped vitality due to
undernourishment.
.•
•.
- The life expectancy of the average person is twenty years
less than his counterpart in the affluent world; that is, he is
denied 30/ of tho life-span of one born in the developed nations:
he is condemned at birth to an early death.
- 800 million of those people arc illiterate and, despite
continued expansion of educational opportunities, even more.of their
children are likely to be so.
e.
Julius Nyerere, President of Tanzania,. has warned the rich
nations; "Poverty is not tho real problem of tho modern world, for
we have the knowledge and tho resources wbioh will enable us to over
come poverty.
The real problem of tho modern world, the thing which
creates misery, wars and hatred among men, is the division of mankind
into rich and poor".
f.
It is not so much tho question of some having more to eat or
better clothes to wear, while others cannot provide oven the basic
requirements; it is rather the power that this wealth gives to some
to dominate, to oppress and to exploit the others.
in 00 .doing,
the rich and powerful justify themselves: "We deserve this wealth
and oowcr: we have put our Porl-niven talents to unn rnrt hp"1’ ''n"‘ nA
-22.
Extent of inequality in India today:
a. Jhile we often and with some justification, blame all our
problems on the greediness of-the affluent, developed nations, the
same ever-widening gap between the "haves" and the "ha:Ve-hots"
appears hero' even.’'’■
'\J't;
*.B.
,'!•jp:
''.M.O:
*-,
or.
1.
nor;:iv it, /. <>I
.n .■ -»}.
-.J'1’ -> j
■ini
,b. iJithin our population of upwards 600 millions-cdfi pdb'pl^1'roughly 250 million live below the "poverty line", that dividing
line''th'at deferiSSa'ias tiarp mirtlmtfm ’dK p'urilivai'' fdrlfTbri’ jtrtiflyidba'K
This'JJis: tpc bd.ttom 4O'”tie1r'c'eh't:''.'Another .2^6''ll ve,!j'irst'
a bo ve't he™ pb Vert y' I'in d'' iff 'humarr' .stfiKB-l/air' t hk1 remaining' '15120.'J ““
per ceht,' in ah a'scehcft'hg';pvra'ini‘dr|j(dpre0ht'-''Brha'dtimlnaTit',Ll Oj
class esT w'it’fr power,''"position "hntf^daiity etiuta't'iaks’ t'hb"\ra^,matb'-'1 ''' 3
rial''Hr1' fUrther'rexpibx£otl.'iffi'--tiF' tWi3t'fiof‘s’.'u®
,3Gsror.gl one cealjiirie ,yssI el blrow arid 5o daei odd '11
.bred
r-p.
In rural India, the top'ten percept own 50^ 'b'f ttfe1 -iinSirr 3
U '31i . • 1.
iv IV '!_» ;
'! J
J, , !■> ■ ■ ", iJi ! J
: Ccr i
, «.«
z'
I• r • VV
while the bottom 50 .per ,c.ent ,p^jp A^ ^t op^ ten p.er ^.ce.ntj ^get .1/3^ of
; j
annual income of the nation, while tha'bottom 50^. get lp.ps5,.thp_n ...J ’ u
this amount for all of their numbers.' 0.1% of the’ populaiiion''owns J
,morQ4M1
thcj wealth of the. orca. /:.
_
;
; ..
d... .The.; PJor" .axe o pgahi's'ecC ' wiT:.hb'^Upplitica1i‘'.pb'wer>,yari,d' ar-e'." "r''L
taken advantage of. 4 slum ;dwb'l’lerr’Admits:., VEV.pri. to; get
sweeper's job, ws havet'o phy h'briVe of Rs. 200/-'"’’
1 .
L-. .: ", \-n-.
■■ ■ JD ,
depo a.- ..' 1 . s iqr: , - n::.:i io r
's
.. e, .. i he .v^ry ,popr (bottom 40. p.c.rc^nt) Ipave less
month to spend.
Most'cannot’ read or write.' ’ .
per
8LI i ll.
;:om arid Io
I o I'-.Idoaq
s
I I'M ges
Ins ecure
Impersonal
Dependable
Conservative
Progress!ve
Flat ure
Emotional
Uncommunicative
Uncooperat ive
Rest less
Helpful
Professional
Frust rat ed
Concerned
Irresponsible
Conf uassd
Backward
Ent husiastic
Dogmat ic
Hard-working
Money-minded
Efficient
Immat ure
Loyal
Insincere
Idealistic
Undependable
0 ver-productive
Apathetic
Encouraging
Risk-taking
Responsible
Supportive
gelf-cont rolled
Unprofessional
Over-sensitive
Impulsive
Appreciative
Sup er ficial
Naive
Exploit ed
Lazy
1.
From the list of adjectives given above, which seem to you best
to describe the urban worker?
Select as many words as you wish.
you wish to add one of yo«r own,
2.
If
feel free to do so.
From the same list, which adjectives seem best to you to des
cribe the unemployed?
3.
From the same list
which adjectives seem best to you to describe
the villager?
4.
From the same list
which adjectives seem
cribe the average student?
best to you to des
-2-
5.
I^rom the same list, which adjectives seem best to you to des
cribe your parents?
6.
From the same list, which adjectives seem best to you to des
cribe yourselves?
HOUSE VISIT SURVEY
1.
Uhat community do you belong to?
2.
How many members are there in your family?
3.
Are all the children ^oing to school?
4.
How many members of tho family earn living?
5.
uhat are the market prices? rice? wheat? dal? oil? etc.?
6.
Can you manage to buy what you need for the family?
7.
Uhat are you most worried about now? low employment?
rising prices? children's education? health? debts? etc.
8.
uhat kind of injustice 'are you facing in your daily life?
unfair practices? discriminations?
9.
do
10.
you get any help from any source in solving your problems?
Uhat kind of support would you like to get from us?
could we help you?
Haw
11-
Uhat makes you feel happy about your life?
12.
Uhat are your hopes and ambitions for the future?
13.
family make-up; ages (children, teenagers, adults, old) and
sex.
14.
Type of house: mud or cement; number of rooms electrified or
not; owned or rented.
15.
Occupation of wage-earners; self-employed or not; farmer,
factory worker, government worker, contract labourer, teacher
et c.
16.
Education; how many literate; how many with basic schooling;
high schooling, higher studies; language(s) spoken.
17.
Income; sources and how it is spent on food, clothing, fuel
and lighting, entertainment, rent and other things.
18.
Savings; in what form
19.
Religion and caste
20.
Medical facilities at family's disposal.
,flt the end of each interview, you should record your findings
to these questions once you have returned home.
D
1.
ro our findings differ according to the section of town we
come from? Why might this be so?
2.
r£w does this "minimum monthly income" compare with the incomes
of the families we met during our house survey last time?
3.
Do the families we met then exceed the number of members of
the "model" family of four we have used on this survey? What
would this mean with regard to their minimum monthly needs?
4.
What may be the consequences when minimum monthly requirements
and income do not meet? Cutting corners? family insecurity?
undernourished and underclothed children? etc.
5.
What are some of the possible consequences of family insecurity?
quarrels? drunkenness? indebtedness bn.it becomes chronic? etc.
6.
Who is to blame for so many people in our community living
under or just on "the poverty line"?
7.
Where does your family shop? What type of rice does your
family buy? What typo of cloth? i-pw much rent?
How much
entertainment goes into your miscellaneous expenses?
8.
Was this a new experience for you, or have you often done
the shopping in the past?
9.
How did you go about choosing the market and the different
shops?
10.
What did you learn from this experience?
an overview of different community health PROGRAMMES IN INDIA
(MODELS AND APPROACHES)
I. INTRODUCTION
Community health approach to health care has been widely reco
gnized as the right alternative for ensuring health to the poor
millions in developing natives. In India too, governmental as
well as voluntary efforts arc made for the promotion of
community health. In the evolution of health care system, this
approach has emerged through a process of dialogue between the
medical and the social sciences in an effort to make the
health care system relevant and responsive to the sociopoliticao- economic realities in the society. Again, in the
process ofevolution and formulation of community health in
terms of its principles, philosophies and methodologies, various
models have been proposed and practised. In this paper an
attempt is made to categorize these models into four, each with
its ’own characteristic features.
Further, each model with its characteristics could be explained
as following a certain approach in community health. These
approaches are broadly divided into three. An understanding
of these three approaches could give us a frame work to assess
as to which approach each models follows. Another interesting
correlation is that each of these three approaches reflects
a certain philosphy of development work.
In the following paragraphs an introduction is made into such
an analytical overview. In the latter part of this paper the
four models with their characteristics are listed out. Under
each model, the particular approach into which it fits into
is also given with certain indicators or assessment.
ii.
Different models in community health
A study of the ongoing projects and the 1 iterature available
on them reveals that in India thole exists different models/
types of commuhity health products. They fall under four
major categories. Each one is run by differ ent types of insti
tutional set ups as big hospitals, small hsopitals, rural
dispensaries, or run by non structured voluntary health/ action
groups. Again, each model is unique in terms of infrastructure,
services rendered, needs met,and the results achieved. It
would be clear from the forthcoming table.
III. DIFFERENT APPRQACHESIN COMMUNITY HEALTH.
Three approaches have been identifyed in community health.
They are : Medical approach, health extension approach,
Comprehensive approach.
Considers health as the absence of
diseases brought about by medical
interventions based on modern sciences and technology and sees
the role of the community(the people) as responding to the
directions given by the medical rrofessionals. It has its
roots in the medical model of health care .which b elieves flfcrt the
eradication ofiill-health depends on doctors and medicines.
.
(a)
Medical approach:
(b) Health extension ap-roach;
Based on accritique of medical
approach. It accepts WHO
defenition ofhcalth as the total physical, mental and social
well being of the individual. Mere advancement of medical
2
technology and the sophistication of services w-uld not bring
health to themajority of th ep conic - especially the poor - and
that the approach should be a.~ planned redistribution of health
care facilities to reach the’ vastness of the society. The
approach also advocates other socio- economic uplift programmes
to enable people to benefit from health care facilities.
care
*
Preventive
is also emphasized.
Views health, the concept of
total well being in the context of
the situational
realities of the individual. - This concept
is elaborated by stating that health, the state ,of tdnl well
being, is also a human condition which does not improve either
by providing more services or mobilizing the community for
providing more health services. It improves only.by having the
community take control and responsibility for decisions about
trhow tomobolize , utilize and distribute services and resour
ces. Here community is thesubj ect, decision maker, It is a
process of conscientization'f organization and capacitaticn of
the community for action, it has bearing on the social,
economic,political andcultural dimensions of human life, in the
sence that the approach strives to bring about changes in then
so that there would emerge a society whete human life would be
more healthy in the complete sense of the word.
.
(c^Comprehensive approach;
IV.
COMMUNITY HEALTH AND THE DIFFERENT APPROACHES IN
DEVELOPMENT;
Development work is based. on certain analysis of the backwardness
of the people. According to the analysis , different philosophy
of development vprk are arrived at. They are mainly three
approaches: Modernization approach,“-welfare appren ch, and social
justice approach. In the context of sneaking about different
approaches in community health work, it wj uld be worth mentioning
these approaches. It is interesting to note that reflections cf
these approaches are found in the three community health
approaches.
Themodernization approach analyses poverty as the lack of
enough production and itmakes efforts to gear up product! n
through advanced! a-..technology in the field of agriculture and
industry. It believes that the result of modernization would
trickle down to the lower strata of society.
(a)
(b) The welfare approach recognizes different classes and castes
existing in the society. It is due to the co-existence of
development and under development in the society. This state
is accepted as a normal reality. Efforts are made to alleviate
the sufferingssof the poor.through organizing relief and
charity work. People are passive receipinnts here. Recently
there has been some changes in this approach and it recognizes
the participation of the people and the mobilization of their
resource. Programmes also have improved remarkably from
relief work to development programmes aimed at the uplift of
the poor, through income generating programme, literacy
programmes, vocational training etc. THjr poor continues
to
exist and the disparity between the rich and the poor also
continues as a reality. Statusquo is not disturbed.
*Conscientization is"an awakening of consciousness, the
development of a critical awareness of a person's on identity
and situation, a reawakening of the capacity to analyse the
causes and consequences of one's own situation and to act 1
logically and reflectively to transform that reality"
(David Millwood)
..3/-
- 3 -
c.
In social jus vice approach a critical analysis of the
society is employed and poverty and baclo/ardmess are under
stood as man made historical reality. The reasons are
attributed to the various forces and the dynamic at work
. in the. society. Poverty is presipitated as a result of
injustice.
Justice could be brought in only through a
restructuring of the society. It could be achieved
through empowering the people through awareness building
and organization. Ultimate development of the poor would
mean fair distribution of the means of production, living
wages, consumption of good food, availability of public
amenities, practice of human values as love, cooperation
and unity.
It becomes clear that the analysis and approaches of
development work has correlation with that of community
health work. Characteristics of modernization approach are
reflected in medical approach and features of welfare
approach find expression in health planning approach. Social
justice ap-roch goes well with, com'Tehensive approach
in terms of its analysis and approach.
V.
T.HE FOUR MODELS AND THF>-p. APPROACHES
IN COMMUNITY HEALTH
As mentioned alreadyythe community health programme existing
in the country could bo classified into four based on the
characteristic. The following tabic would give that.
Under tach ;rogramme a note is made as to which approach of
community health it belongs to. To make it clear six
indicators are given based on which bhiso assesment
is made. These indicators are: role of health services,
role of professional, role of community worker, Community
•participation, evaluation and financial support. For each
approach these indicators show different explanations.
MODEL
A ^CHARACTERISTICS
I.
Type of institution/
infrastructure
Nature of Services
Rendered
NeecS m et
Capital intensivej highly- Treatment of minor
- Extensible service from
sophisticated and insti
hospital.
physical ailments.
tutionalized big hospitals. - Curative care.
- Running village clinics.
- Referral and free
Mobile medical team with
- Referral service, free
transportaion to the
doctor a medicines.
medicines.
hospital.
- weekly or fortnightly visi s.
Result- Qualitative changes.
- People become more conscious abo
sickness and medicines.
- more patients in the hospital
- feeling of dependence in the
people, demanding free services.
- shift from home remedies and
indigenous medicines.
B.THE APPROACH FOLLOWED.
The approach followed is medical approach.
assesment on that.
..
The following are six indicators vhich would help us to make an
Indicators.
Explanation.
a. Role of health service
b. Role of Medical Professional
- means to improve the health status of the people
- Key to the programme- manager, planner, problem solver, coach, consultant,
clinician, leader, teacher, evaluator.
c. Role of community health worker
- a means by which medical advances could be applied more rapidly and
effectively.
d. Community participation
- a means to ensuiie.mdreuaceeptibility and utilization of services.
e. Evaluation
- Based on analysis and interpretation of statistics which reflect the scope
and results of applied medical science and technology.
f. Financial support.
- needed to create, expand and maintain the service.
MODEL . II
A. CHARACTERISTICS
Type of institution/
infrastructure.
Nature of services
r end er ed.
Capital intensive, sophi
sticated and institutiona
lised small hospitals.
- Extension services,
- Treatment of minor
- people meeting in groups.
- curative and preventive
- learn some preventive methods.
ailments.
care.
- Referral and free
- More patients in the hospital
- Village clinics
transporation
- Learn that they can do something
- Referral services.
to the hospital.
about health.
- Medicines at reduced
- personal and environ
rates.
mental hygeine.
- weekly or fortnightly
• visits-.- - ■ - HBalth Education
/
- MCH programmes/ immunization.
- Village Health Workers with
medical kit,
Medical team with
without doctor.
or
Needs met
Results- Qualitative changes.
B.APPROACH FOLLOWED
The approach followed is Medical approach. But there are certain changes, in the sense that it is not strictly
Medical approach. There is an indlinaticn towards Health Extention approach.
Indicators.
Explanation.
a. Role of health services.
- Means to improve the health status of the people.
- Medical professionalcontinues to te the key personnel.
gain a role -here.
b. Role of medical professional
c. Role of Community Health 'Worker
(CHW)
d. Community participation
e. Evaluation
f. Financial support
But, para medicals
- along with being a person to ensure more community acceptability for medicine?.
CHW also imparts preventive health education.
- a means to ensure more acceptability to medicines as well as a means to
disseminate ideas of preventive health education.
- based on analysis and interpretation of health statistics that shows the scop
and result of applied medical science as well as the effectiveness of prevent'•
health education.
- needed to create, expand and maintain the service.
A. CHARACTERISTICS
MODEL .III.
Type of institution/
infra s tn uct ur eT
Nature of services
r end er ed .
Needs met.
-Preventive, promotive
Rural health centres
and curative.
manned by nurses, not
institionalized, still very - Community health workers with simple medicines.
much str uc t ur ed.
- Health education, Adult
Education
A team composed of a
nurse and social
- Smallincome generating
projects
workers.
- kitchen garden
- M C H
- Collaboration with gi>vt
and other agencies.
- village meetings and
discussions on different
village problems.
- promotion of collective
action.
Better environmental
sanitation.
M.C.H. Services.
Supplimentary income
for a section of the
population.
Resulig - Qualitative changes.
- people become aware of the important
of preventive medical care.
- Less patients to go. to the hospit-l
- Better child care.
- people try to see health in relatic
to economic backwardness.
- Develop more interaction among the
villages, formation of small infor
gr oup s, mahilamand als.
- people’oecame aware of their collect'.
str ength.
B. APPROACH FOLLOWED.
The.approach followed is Health Extension approach. The following indicators would make it clear.
Indicators.
Explanations.
a. Role of health services.
- as it vews that good health is the result of planned health servicer,
experts from other fields as economists, social workers, etc- are also
involved to make services effective.
b. Role of medical professional
- The medical professional is viewed as a component rather than key. Fort .v
experts from other disciplines are also involved - economists, soci'1
workers, etc. Attempts are also made to include community leaders.
c. Role of Community Health Worker
- CHW is considered as an agent of change - and works as a multi purpose v
worker which include medical services, prevention, public health work, h
education, nutrition education, food production and housing improvements.
d. Community participation.
- Participation of the community is considered important because it provid
a resourcebase, a means to mobilize more resource - personnel, money and
material. Mainly it involves the community leaders.
e. Evaluation.
- Concerned with assesing whether a programme with a variety of activities
(raging fromfhealth to economic development programmes) provides the moss
benefits in terms of health improvements for the least amount of resourc
f. Financial support.
- Used to build small health centres and to generate community resources man power, money and material. The programme has to be made self
supp orting.
MODEL . IV
Type of institution/
infrastructure
Rural health centres/
action groups.
Flexible and non
structured.
One team composed of a
nurse and activist.
A. CHARACTERISTICS .
Nature of service
Render ed,
- Services aimed at building
healthy communities.
Community diagnosis.
- Critical understanding of
health and its relation to
unjust social order.
- Awareness building through
non-formal education
programmes.
-Organizing the people for
collective action.
-Exposing social illness.
- Formation of Action groups,
Mahila mandals, youth clubs,
village committees, Farmer's
club, Trade unions.
Needs met
Basic needs met by the
people through their
organized efforts.
Better services from
the government.
Results - Qualitative changes.
- Participation and collective acti
of the people to build up a health
corn munit y/ s oc ie ty.
- Increased self confidence and
independency.
- faith in their own power to fight
for a healty society.
- Health is considered as a right
duty andat the same timeseen as a
pollticial issue.
- people struggling against social
injustices.
- Cooperation among the people based
on c rticial understanding of soci 1
realities.
- New forms of politics and new for;
peoples' movement.
- Alternative indigenous medics L sy:;'developed.
- Demanding services from
the Govt, from health
as well as other depart
ments.
- Identifying and training
village animators.
- Promotion of low cost and
simple home remedies.
B . APPROACHES POLL WED
In this model the comprehensive approach
is followed.
The following explanation would make it clear.
Indicators.
Explanations.
a. Role of health services.
- the concept of health is totally integrated into the socio-political febric
of the community. Hence health services are a part of a stro.tegy( or an
entry point) for development and a tool in process of community growth.
of
- Since the role/health service is to enable change in the existing social!
structures (to bring about equity of opportunities andservices), the profession
is viewed as a resource- an enabler , educator and a stimulus.
The communiis the decision maker which difines the role of the professionals and the
professional is accountable to the people.
b. Role of medical professional
c. Role of communityhealth worker.
- Community Health Worker(CHW) is anagent of change, an educator, a volunteer
selected by the community. Uses health work primarly as a means of bringin.'
about change in the attitudesand behaviours, and in the long run, social
structures through health and development activities. Thus, CHW works nowrds
social justice and social, .;■ /’ political and bbbnomic equality as well as
carr.ying out the health and traditional community development tasks.
CHV-i
could be better called, community level worker(CLW) since the wrk is total
.development work.
d. Community participation.
- Community participation in health is a step which will help people gain
control over their own lives by colJactively working towards making the
socio economic and political structures compatible with and conducive to
heaith and development of the poor. It'
starts with awareness building an ■
organization. Community is the decision maker in the community programme,
and through such involvement they go through a process of learning to
live together, think together and work together and take control of ^oliciej
which affect their lives.
e. Evaluation.
- The community!s the evaluator,- it is participatory evaluation methodscommunity decides onn the obj ectives,priorities and methodologies of the
process. The development worker, as an enabler helpes the community and
workd with them. The evaluation itself is a tool and a method for
community awareness, self determination and growth. In the entire
process, stress is laid on the qualitative aspects of the people -and
the efforts at bringingabout change^in the existing health delivery-;/
system and theestablishment of alternateve models of the people
f. Financial support
-To spark off a programme finance is needed. But the goal is to start
a programme which is able to b e sustained through community contribution an
commitment not through outside finances
.
*
'Ehe investment is in education,
rather than technology and expanded services. It also means money to
identify and develop indigenous resources in terms of man power, materials
and support. In terms of health aid, it looks for seed money. Maximum
efforts are made to make use of government funds but not at the cost of
allowing them to dictate terms. It should never hamper the community
in its precess of growth towards awareness and organization.
i.O
CONCLUSION:
Community health is a term understood and interpreted in diff
erent ’.-ays by different people. This is due to the differences
in the analysis of the ill health. Based on one's analysis
the programme that is initiated would conform to a particular
approach and philosophy.
This paper, we think, would help the implementors', on of commun-r
ity health programmes ns well as those who intend to start one
to develop a still more reflective understanding.
This
understanding blended with out commitment to the poor would
help us all. to make out involvement more meaningful.
* & # jjc
#
"b .
id/83 : IOC
ab:ka 11/8? :100
>}< 'Jfi
#
EXTRACTED IT. CM THE REPORT OF A SYMPOSIUM ORGANISED
JOINTLY I'Y INDIAN COUNCIL OF MEDICAL RESEARCH ADD
. INDlfiN COUNCIL CI SOCIAL SCIENCE RESEARCH ON BALTER
NATIVE AFFROACMNi TO HEALTH CARE" AT TEE NATIONAL
USTITUTS OF i'.UTRITION, HYDEFAPAD FROM 27TH TO 3OTH
OCTOBER-1976- -
• SERVICE RESPONSIBILITY OF A DEPARTiECT OF COM" UNITY
I-EDICrnS THROUGH A HEALTH CO-ORZRATIVE
B. MAHADEVAN
*
Background
Health facilities in rural areas in the country were provided.
through Primary Health Centres 9(PHCs) started as part of an national
rural development scheme called "Co.uunity Programmes" in 1952, with a
very modest staff in each centre to form the nucleus of integrated health
services and eater to the need of about 60,000 population in a Block.
There arc now over 5,200 PHCs, each Centre caters to a population ranging
from SO,000 to 1,20,000. Each PHC therefore has to take care of a very
large number of persons. The scheme was extended to involve Nodical
Colleges in rural health work and through deliberations of many committees
tile status of PHCs was improved both qualitatively and quantitatively.
An integrated approach of providing health services to the rural people,
with the provision of two doctors to every PNC and a Basic Health Worker
(BHW) with an Auxiliary Nurse i'idwife (ANii) to every 10,000 population,
was attempted.
A pilot Mbbile-cum-Training-cum-Serviccs Hospital Scheme was
introduced in some Medical Colleges with a view to involve medical and
nursing students in rural community medicine. The intention was to
establish ultimately one mobile hospital per medical college, boro
medical Colleges were established with t o sole purpose of providing
rural health, services. Specialist car.ps were organised for cataract
operations, vasectomy and tubectomy. Alt' ough the government’s idea is
to train doctors for rural areas, these doctors arc not attracted to
such places. Hie nri.gration of Indian doctors to the more developed
countries continues . Evon passing a Parlia: ent Act which empowers
government to oblige doctors and engineers below the age of 30,years
to work for a period of four years in rural areas, the problem remains un
solved duo to the inability of providing reasonable living conditions
for them in villages.
Some medical colleges like vcllorc Christian Nodical College
incorporated in their teaching program,..c, the rural dimension in signi
ficant way. The organisers of the community Health Centre, have found
that it costs a’out Rs. 8.50 per person per year, which includes
preventive, premotive-and curative servi ces. The administration is not
very happy about this project due to the high recurring costs.
*Maj. Gen. B. Mahadevan PVSM, A.VSM Professor and Head of the
Department of Community icdicinp, St. John's rfedical College Bangalore
(Karnataka).
....2/-
- 2 The Kerala Govern;-.ent with Government of India's initial
one time grants, have established Health Co-operatives in 11 districts.
Doctors arc encouraged to seek self-employ cent in these fco-opcratives.
Doctors and paramedical staff take shares in these co-operatives. A
certain foe is levied on services, and medicines arc also paid for.
One is loolcing forward anxiously to the success'of the scheme. The
initial reaction of the people has been good.
Voluntary agencies have established a large, number of
hospitals in urban areas. However, funds arc not available to these
hospitals for any significant rural health work, although an increasing
number of dispensaries arc being opened in the rural sections of the
gountry.
From the facts and figures just given, it is clear that
the government in spite of its herculean efforts has not been able
to seriously tackle the problem and with t’c scarce allotments made
for the health services, no tangible improvements is possible in the
near future. no voluntary agency car hope to embark on a scheme where
even the government has failed irut is in a better position to try out
new methods through pilot projects.
When -planning rural health services, one has to consider
two components, namely the delivery of package of rural health
services in villages and recruit-ent of personnel who will deliver
tlic same. At the same tire, there is an inescapable need for com
plementary services which will develop- ’■■he villages economy.and .
education of the rural people, i .any rural health seboros taken up
enthusiastically at the beginning flounder for lack of popular support
that has to be expressed by financial contributions. This is the
crux of the matter. Any health delivery scheme should be a self- .
sufficient fiscal entity. ' This may be a limiting factor but the only
sound way of attempting to solvo rural health problems, is to start
it in places where conditions are favourable for the introduction of
self-supporting scheme.
Funds for rural health schemes may be raised through many ways
1. Tagging health services to co-opcrativcs. -
To start hcalt’’ co-opgrativcs by themselves is difficult
as health holds a low priority in the felt needs of the people
and nay not get the required support in the initial- stages. The
procedure of tagging on health services to existing-.co-operatives
has many advantages - good leadership, a readymade frame work of
Community administration for introduction of effective health
services and corariunity cnvoivcmont, as channels of communication
with the people ha.vc already been established. Co-operative Dairying
and larkcting Co-operative of different commodities like grains,
cereals, cottage industrial products etc., lend, themselves admirably
to this type of health services.
2. Running health services with assistance from factory
administration where labourers are from villages nearby.
A minimal deduction at the soiree of salary and a contri
bution from the factory management will help to build-up the required
funds and fortaction of a health co-operative. Geographical location
of industries and rural la.bour in close proximity arc limiting factors
but the- scheme is worthy of trial, in special areas.
3*
Assistance from Panchayats.
Please where Fhnebayats and the people arc interested in
health services and arc willing to contribute to th.. same, may venture
on this method, but unless sufficient funds arc forthcoming regularly
and persistently the schcv’c will collapse.
■ o.'r
- 3 -
A devoted team of health workers can establish themselves
in a village and build-up the required clientele and popular opinion.
The people car. then be induced to-form a co-operative and directly
employ the doctor and essential paramedical staff. Until, such time,
a central agency or other funding agency may have to meet the expenses;
This can bo attempted even without forming a co-operative in areas of
affluence, where people arc willing to pay for the health services and
employ the doctor and other staff through collection of revenue for the
purpose.
The ’bllv-r
ilk Co-operative (iE-C)
Ifellur is a village in Kolar district of Ka.rna.taka, situated
about 60 km. from the city of bangalore. The H.llur /ilk Cooperative(IS C) was an established concern with a sound and progressive leader
ship and has been functioning for many years. In addition to production
and sole of milk, it provides other benefits like provision of fodder'
and cattle foods, tractor facilities and loons at low rates of interest.
Eesidos the people of i'allur, two other villages, iiuthur
and Kachahalli arc members of the Co-operative and the total
population covered is a- out 3,000. These villages have a sill;
farm cooperative besides cooperative dairying. The economic
position was satisfactory, and therefore all. conditions wore
favourable for the introduction of other self-supporting schemes.
The inspiration for establishment of a Comprehensive
Health Care Programme for the cooperative members and their families
of these villages, came from Sr. Anne Cumins of Coordinating Agency
for Health PLannin.- and Th?. Jones of the Catholic Bishop Conference
of India. With those pioneers, the Dean and the Department of
Community Medicine of St. John's ’-bdical College, representatives
of the Karnataka Government and Bangalore Government Dairy with
leaders of the MIC worked out a scheme for tagging on a health
services to it.
The main objectives of the Mailin’ Health Project arc:
1. To study and devise methods by which tie financial
base needed for effective health services could
emerge from the people themselves in a self-sus
taining manner;
2. To help in the establishment of rural health centres
with the staff and rendering of effective health ser
vices to a wide circle of needy -people without
distinction of ro.ee, caste or creed;
3« To study the required strategy and methodology for
the effective rendering of primary health care in
rural areas by trying to determine the priority
areas in health care and devising the structure
found suitable to village conditions;
4.
To help in those developmental activities which
are very necessary to ensure effective rendering
of health services in rural areas; and
To train intern doctors, nurses and other medical
and paramedical- staff for the purpose of rendering
assistance■in rural areas.
..V-
- 4 -
The St. Join's ibdical College arid its Depart; ent of
Com unity Ibdicine were to be mainly concerned in acting as a
catalytic-agency,, in the formation of self-sustaining rural com
munity health scheme, fulfilling the above objectives.
Sponsorship was by the following agencies organisations
1. h'C.
2
• Coordinating Agency for Health Hanning
3
• Catholic I-ishops Conference of India
4. St. John’s Medical College (Dept, of Community
lie licine ).
Source of fun’s
It was csti-£.tcd that a monthly budget of Rs. 2,500-3,000
would bo. required for Training 'the Health Co-operative and financial
support was forthcoming by a joint contribution of three paisc per
litre of milk from, the UiC and bangalore Dairy, in a phased formula
as shown in Table 1 below. Ultimately the 11-0 was to completely
finance trio scheme.
Table 1 - Contribution to the Health Co-operative.
Year
I
I
I
;
Contributeons/litrc
I
lELlk Co-operative
![
Bangalore Dairy
i
First
Second
Third
1
1
)
1
2p
3p ■
I
;
2p
1p
nil
* Raise
This budget was adequate tc support a health programme,
organised by a Medical Officer, Hurso Compounder and an Ayah. The
staff were appointed by the Health Co-operative Committee.
The Health Co-operative Committee included the following
members:
Chairman, TH-3D
Secretary, 1M3.
Doan, St..John's Medical College Bangalore.
Head, of the Department, of Community.ibdicinc, St. John's Medical College.
Dircctor/Gcncral Manager, Bangalore Dairy.
Representative of State Health Service.
Medical Officer Mallur Health Co-operative (Secretary)
The composition ensured integrated planning between the
Ifi-C and Health Co-opcratiyo.
The Health Co-operative got off to a good start by being
inaugurated on 19 March 1973 by the Minister of Animal Husbandary.
Dr. V..-K. Rajkumar, a Senior House Officer in St. Martha's Hospital,
joined as Resident Medical Officer in-charge of the Co-operative. This
Medical Officer by dedicated work and self-sacrifice, made the iallur
Health Co-operative a successful enterprise.
Coverage, services and benefits provided
...5/-
-5 ~
The St. John's iedieal College adopted this Health Coopcrativo as c. rural training centre for interns. -Visits by
specialists of other departments including specialists campswere organised. At present, four interns arc attached at any one
time for whom residential accommodation lias been provided by the
i-^-C on a rental basis. The interns conduct baseline demographic
surveys, immunisation and school health programmes, special health
projects and mass health education, programmes.
The Health Co-operative Committee meets by turns, a.t
hallur and at St. John's Medical College, to discuss progress and
plan for the future.
>
The Health team co mrisiny'Dr. Eajliuaar, Uss 1'hria and
interns under the technical supervision of department of
Community Medicine has made good contact with the villagers and
a comprehensive health are programme has been introduced. • The
community of I'ellur and other member villages with a population of
3,000, actively participate in all programmes.■ They have no
unreasonable expectations or demands, as the health, project is their
own contribution. This is a basic difference between Health Centres
organised through cooperatives and governmental-a' encics. The
leaders are actively involved in. the plannin and organisation as
tho Chairman, - ’. C is the Chairman of the Health. Co-operative Committee
and the Secretary -.1 C is its member. Paramedical workers arc drawn
from the village co.-munity and trained for community health work.
r
.
: " 1.. .
-y .. ■■ ■" ■
■ t. ' ■
. :.
The young-Farmers Association. actively assists in many of the
health programmes. They help interns in their surveys, programmes
of immunization and environmental sanitation,-including chlorination
of wells and construction of sanitary latrines .• Thejg also organise
the physical arrangements for the mass health education programmes .
The i ahila l.'andal under the dynamic guidance of iirs. Rajku.raar, runs
a nursery school and acts as a farua where health, education, applird.
nutrition program:yes and mothercraft arc taught to.the womenfolk of
the village.
• .-
The health team and interns organise the following
services with community participation:
Personal services
1. Curative Clinic (daily outpatients):
2. Maternity and child health services:
(i)
(ii)
(iii)
(iv)
antenatal care,
midwifery (domiciliary),
postnatal care, and
under five clinics (domiciliary).
3« School health services for village schools.
4. Immunization programmes for smallpox, triple antigen,
tetanus toxoid, BCG, typhoid, and cholera.
5.
Tuberculosis (TB) and Leprosy-case detection,
treatment and follow-up.
■
6.
Motivation for family planntag.
7.
Specialist camps at l.allur (periodical visits by
St. ihrtha's Hospital specialists). '
8.
Hospital referrals.
9« Family record maintenance.
Community Services
1. Protection of well water supplies by chlorination.
2. Fopularisati c--.
construction. of sanitary latri--us,
- 6 3.
Collection of health data through periodical surveys.
4.
Coordination and cooperation with 'ovornnent health
personnel in national health programme activities.
5- Health education at personal, group and villa.gc levels.
6.
Nutrition education and nutrition supplementation.
Programmes.
Members of the "ilk Co-operative and. their families arc.
entitled to all the above mentioned services free of cost, lion
members coming from other surrounding villages pay.for drugs/
dressings arid minor surgery. All -preventive, and promotive work arc
given free to all categories• Table U shows the number of member
and non-mombor families in each village.
Table II - Number of member and non-mombor families in
each village.
Families
Village
Ifellur
liithur
Kachahalli
Ehatcrcnhalli
Harrulunagcnahalli
.Member
Non-membor
188
63
30
6.
202
124
21
14
18
304
379
.17
45 percent
Total
390 '
■
187
51
.'■31
.
24
.
•
683
55-5 percent
Personnel, facilities, resources and mode of payment for personnel
The Health Co-operative in November 1973 was joined by
anothcr dedicated worker, I aria', an Italian Public Health Nurse,
She with her companion Cathy, a volunteer from Canada, looked after
the maternal and child health work.
■Within five months of starting the project (August 1973),
the cost of fodder went up and milk production of the milk Cc-opcrativc
fell as some members began to sell, out on higher rates. The 1-3IC took
a decision, much to' the discomfiture of the Government Dairy Authorities,
to sell directly to private parties in Bangalore, who offered better
prices. The Govt. Dairy, therefore, stopped its contribution of two
paiso per litre of milk as health subsidy, and the Health Co-operative
was in a critical situation. It is at this stage a momentous decision was
taken by the responsible village leaders who were more than convinced
of the positive role of the Health. Centro and its staff in improving
the health status of the people in i’allur and other villages. The Milk
Co-operative was doing well and decided to contribute five paiso per
litre of mill-: for health and took over financial responsibility for
running the Health Centre. Tliis financial strategy on the part of
village leaders resulted in the project becoming a viable unit. The
i'filk Co-operative has borne the entire recurring costs of the health
project ever since, and Table IH gives the Incomo/Sxponditurc position
for the period July 1974 "to June 1975.
Table IH - Recurring Costs - Year - July = 1974 to June 1975.
Total milk production
6,27,898 litres
Income estimated at five naiso/litrc Rs .31,394.90
Actual income received from MiC
Rs .33,100 .CO
Total expenditure for the year
Rs .33,790.74
- 7 -
Present position: Salaries:
At present ti c; Iilk Co-operative is supplying about 2,000
litres of milk per day to Bangalore. Each member is now contributing
six paise per litre of milk a day. The contribution towards the; Health
Centre is Rs.3,600.00 per month.
The actual u.-eponditure per month is indicated below:
Salaries
(licdiccl Officer, 'Clerk, Compounder,.
A.H..H. and Ayah)
Rs. 1,600.CO
Drugs
Rs. 1,500.00
Rent and electricity
Rs.
200.00
Miscellaneous
Rs.
250.00
TOTAL:
Rs. 3,500.00
In ease the actual expenditure exceeds this amount, the
extra expenditure is met by the Milk Co-oporativc. The Staff of the
Health Centre consist of a Medical Officer, an. AIS 1, a compounder, an
Ayah and a clerk.
In addition, members of the Youth Association, women’s
Association/and Village Fanchayat participate in the activities of
the Health Centre.
'Although the Mellur Health project is mainly financed by
the iallur Hille Co-operative, it also receives help and technical
direction from St. John's Medical College and the Government Health
Services. These inputs arc shown in Table IV.
Table IV - Inputs from other agencies/organisations.
Source
Capital
Recurring
1 . Mallur Milk
Cooperative
Buildings, furniture,
refrigerator health
education material
Salaries, rent/
electricity, drugs,
general stores and
petrol.
2. St. John’s Medical
College
Physicians and mid
wifery kit, minor
sur gi cal e qu.ipment,
motor cycle (on loan
through WICEF)
Interns services,
specialist services
and rent for interns
quarters.
3• Government
Health Services
Vaccines, vitamin A,
Iron and folic acid
supplement, family
planning devices, sur
veillance of communi
cable diseases (through .
HIC, Sidlaghatta),
health education films
(tlirough Health Edu
cation Department of
Director of Health
Services).
Factors affecting quality of services, difficulties faced, methods of
enforcement of control ■<' ovaluat’o”
- 8 The experience over the last two and a half years ’as shown
tint:
(i)
A health function can be grafted on to an economic co
operative ;
(ii)
A sound cooperative such as iliC can support substanti
ally the recurring costs of a health programme;
(iii)
Tagging on of a health function to a cooperative benefits
not only the members aid their families but also the
nonmombers who got indirect benefits of professional
services, preventive and promotivc programmes.
The Departx: it of Community Ifedicino and its staff were
mainly concerned in actin,; as a catalytic agent, in tho formation of a
self-sustaining rural community health scheme. An oxperieiacnt was
embarked upon and the liallur Project is this experiment. A total
health care programme can be effectively delivered through a cooperative
in rural areas. The 1MC is oven contemplating construction of a 15
bedded hospital at iialiur, with the help of government and its own funds.
Further, the Health Centro with its working philosophy, has
indirectly helped the Department of Community icdicinc to conceptualise a
primary health care system for training of future physicians, so that they
play their rightful rolo in a contemporary society.
The health team and interns have played an important role
in the development of the "village in general and health aspects in
particular. Attempts .arc being made to increase the membership.
of the sill: cooperative by purchase of more cows and increasing
enrolment. Other economic activities such as development of village/
cottage industries and handicrafts and ensuring sale of products, arc
contemplated • It is fully realised that in tho planning of such selfsupporting programmes, the health team has to be actively supported by
other members who will attend to the social and economic development
problems of the community. Success or failure would depend on tackling
the financial side.efficiently.
The quality of promotivc and curative services would have to
be improved. Simpler skills, cheaper drugs and intermediate technology
have to be introduced to suit rural conditions. A drive to improver the
education of the people, including health education, is to be attempted
through tho use of Village Level Workers. Their training Programme is
being organised. Whether there lias been an improvement in tho morbidity
and mortality statistics at biallur, subsequent to the introduction of
these cooperatives in comparison-tri.th other areas in the vicinity, needs
study and this has been taker was a health project.
The question of introducting such"self-sustaining Co-op
erative Schemes to other areas around Sangelorc is under active con
sideration. These arc challenges that have to be met in rural India and
it is hoped that with the cooperation and participation that are readily
forthcoming from the simple rural folic, the economic and health projects
will moot with success.
.
.
Conclusion
A good and well informed faculty with modern concepts of
medical education, has a capacity for extensive research in the "organisation
and delivery of health services through experiment, models and pilot projects.
Medical educators in general, and faculty staff of departments of Community
Medicine in particular, must assure their share of responsibility for meeting
the quantitative as well as qualitative needs of the people and must bo
concerned not only with tl'ic basic mission of the university or .government
which is learning, but also actively help the people of a locality or
region in organising and running their own primary health care services.
_ o _
For establishing an effective and viable primary health care
system, the cooperation of the local corvunity wv.st be ensured - In fact,
the people should be adec-vatoly motivated, involve-'1 in decision raking
and actively participate in health pro.'.raur os, so that ultimately it
becomes their own '‘peoples programme”. Local resources such as cooper
atives, agriculture, manpower, buildings and most important of all
local leadership, should bo used to solve o.ad finance the local programmes.It is desirable that the primary health care system should be a self-suffi
cient fiscal entity. Community priorities arc more likely to be met if the
people themselves raise and spend the resources required. A “total health”
approach is essential, promotional, preventive and curative care need to be
completely integrated•
0O0 -
Voluntary Health Association of India
C-14, Community Centre
Safdarjung Development Area
New Delhi-110016
Telegrams : VOLHEALTH
New Delhi-110016
Phone : 652007, 652008
maintaining ongoing recdrds
Now that we have decided with the ccmmunity the work that vre will do,
it is important to keep a record of this work.
Why are records important?
1.
Pregnancy, birth, illness and death are facts of life. To give
the required attention to pregnant women, we need to know when
they are pregnant. To give care to tinder fives we need to know
when a child is born and watch its growth. To-make a community
realise that a lot of diseases are preventable, we need to record
the illnesses they suffer from and show- how many of the people
stiffer from a preventable illness. Therefore a good record system
helps us in our work i.e. in setting objectives, evaluating our
work and in re-setting objectives.
2.
Vfe may be taking the help of the PHG for vaccines. In such a case
we are required to submit records of the children vre vaccinated.
So records help us while dealing with, the Government.
3.
Most of us have to prepare yearly reports for our institution. If we
have taken funds frem an agency we need to give this agency a report
of our work. Records help us to prepare reports.
The most important reason for keeping records is to have useful information
which can be used by us and the community in taking decisions about our
work. A lot of us spend upto 6C$ of our time trying to maintain records
and getting information from than. This is not necessary if we use a simple
and effective record system.
Below, vre suggest a simple and useful way of recording information about:
1.
2.
3.
Children's Services
Maternal Services
OPD Services
,<
We will look at each of these one by one.
CHILDREN'S SERVICES
In any vi 11 age, children under five years of age are most likely to fall
sick -and even die. A child's growth has to be followed carefully till
the age of five.
Necessary information about children in this age group should be recorded
in
A.
a separate section of the same register in which
vre recorded the baseline survey;
B.
the road to health card.
It is necessary to do this because the road to health card should be kept
with the mother. Since you also need a record of children's services for
your reference, you should maintain these records in your register.
2
A.
:
What to record in your children's services register?
A sample table giving the information to be recorded is attached
at the end of this paper (Table I).
How to maintain the children's services records?
1.
Eater the names of all the under fives in your village in this
register and fill in the information for each child. If you
have done the baseline survey you can take this information
from there.
2.
Each newborn child should be entered immediately in the
children's service register.
3.
Very often we have more than one child with the same name,
or a similar name. This makes it difficult to record details'
of the child in the correct place, specially in a busy clinic.
We therefore suggest that you write the child's number frem
the road to health card Jin column 2 as shown in Table I).
This way when a mother brings her child to the clinic you can
see the child's number from the road to health card and locate
the number in your register. This is easier than trying to
find the child's name.
4.
In column 7, 8 and 9 enter the date on which each dose of
immunization is given.
5.
In column 10, record 4 he weight of the child each month. If
you weigh the child for the first time in April, draw a line
across January to March to show that you first weighed the
child in April. If a child leaves the village for a few months,
write the reason for the absence in these months.
,.6.
1
In column 11, you should record in RED INK such information
about the child:
-
chronic illness
eg. TB, Night blindness
reason for special care
eg. Premature baby
Changes in children's services should also be recorded in column
IK Given below are some examples:
a)
If a child becomes more than five years old, draw a
line across all the columns next to the child's name
and write in Remarks (column 11) 'Over Five'.
b)
If a child leaves the village permanently, draw a
line across all the columns next to the child's name
and write in Remarks (column 11) 'Left village'.
c)
If a new family comes to live permanently in the vi 11 age
and has a child under five years of age, enter its name
•in the register and write in Remarks (column 11)
'New in vi 11 age'.
d)
If a child dies draw a red line across all the columns
next to the child's nane .and write in remarks (column 11)
'Dead'. Also enter date and reason of death.
3/
HJWTO PREPARE A SUMMARY OF CHILDREN'S SERVICES FOR ONE YEAR ?
Useful Information
How to find this from your
re co rds?
1.
Total Number of children attended
by you last year
Count al 1 the entries in
column 2 (Child’s Number)
2.
Total Number of new births in last
year
Count all children bom in
last year by seeing column 6
(Date of birth)
3.
Total Number of children that died
in last year
Count all deaths recorded in
column 11 (Remarks).
4.
Total Number of children that left
the village permanently
Count all children that left
village in column n(Remarks).
5.
Total Number of children over five
Count 'all children over five
in column 11 (Ranarks).
6.
Cases of significant illness in
under fives
Write name of illness. Count
cases of illnesses recorded in
column 11 (Remarks)
7.
Immunization coverage
Count Number of children '
immunized from column 7,8,9.
8.
Number of malnourished children
See from road to health charts
of all under fives (explained
in next section)
9.
Number of under..fives on your
records at the end of year
To calculate, this, write down:
Total Number of
children attended
last year
= (a)
Number of deaths
in last year
= (b)
Number of children
left vi 11 age
permanently during
last year
= (c)
Number of children
Over Five
= (d)
Add b + c + d
=.(E)
Number of under fives
on your records at
the end of the year
= a^-E
4/
:
B.
4
:
How to maintain the Road to Health Cards ?
The Road to Health Card is a very good way of checking the growth of a
child from birth to the age of 5 years. The chart from birth to 3
years is given on one side of the card and the 4th and 5th years are
on the reverse side.
How to use the Road to Health Card ?
1.
When a child under five years first canes to the clinic, MAKE A
CALENDAR TOR THE CHILD ON THE ROAD TO HEALTH CARD. The way to make
the calendar is given below:
a)
Find out the month and year in which the child was born.
If the mother does not know the exact month of birth, estimate
the month of birth as correctly as you can. It may be easier
for the mother to remember that her child was born
-
before or after a particular festival
before or after the harvest
before or after any major event
b)
Once you know or have estimated the birth month and year,
write this month and year in the box on the extreme left
of the card. This box has dark lines and 'At birth' is
written next to the box.
c)
You will also find a box with dark lines at the beginning
of each of the five
*
years. Write the birth month in each
of these boxes.
d)
Now, write the names of the following months and year in
between the dark boxes. Remember to change the year each
time January is reached. You will now have a calendar of
the child for 5 years.
In the above example, the child was bom in APRIL 19$O.
5/
5
How to record weights?
a)
If the child is weighed At Birth or a few days later, enter
the weight in the 1st column.
b)
If the child is'weighed for the first time, when it is already
sane months old, enter the weight in the appropriate column.
eg: If the child is bom in April 1980 and is weighed for the
first time, in June *
81, find June '81 in the child's
calendar you have just made and enter the weight in this
column.
How to assess the growth of the child?
THE DIRECTION OF THE CHILD'S GROWTH CURVE SHOWS THE CHILD'S HEALTH.
1.
The weight of a healthy child should increase every month,
The curve for a healthy child should look like this:
2.
If the child's curve is straight, eg:.
.
this
means the child is not gaining weight. This is a dnager sign.
You should find out from the mother if the child is:
a)
b)
c)
eating well
active or not
has any symptoms of illness
diarrhoea.
.
/
....
eg: cold, cough,fever,
Tell the mother to feed- the child at least 5 times each day and
to watch the child carefully.
3.
If the child's curve goes down eg:
this means the child
is losing weight. This is very d angerou^- even if the child's
curve is within the Road to Health Curve. Xs-The child may be ill.
Find out from the mother the reason for the loss of weight. Ask
specially for symptoms of any illness. Tell the mother to give
the child special care and to feed the child well. You should
also make it a point to give this child special attention.
MAKE SURE THAT YOU WEEOi THE CHILD EVERY'MJNIH.
This card should be kept with the mother.
Explain the card to her.
Each time the child is weighed, tell her about the state of her
child's health. Also tell her if -her child needs special care.
The mother needs to keep the card with her because she is the person
most responsible for her child's well being.
You only need to collect the card from the mothers once in a year
in order to analyse the number of malnourished children in your
programme.
6
MATERNAL SERVICES
All pregnant mothers need good Antenatal coverage (ANC). The objective
of giving Antenatal Coverage is to ensure that the mother
has a normal, pregnancy
has a normal delivery and
gives birth to a normal baby
In order to do this we must have’on our records the names and details of all
pregnant mothers in our villages.
What to record:
A sample of the records to be maintained is attached at the end of this
paper (Table II).
How to maintain these records:
1.
It is easier.for us to give antenatal coverage if we know -which
pregnant women are going to deliver in a particular month. We therefore
enter names of pregnant women under the month they are due for delivery.
eg:
2.
If yop see a pregnant woman for the first time, in May and she is
due to deliver in October, enter her name under the month of
October. In order to maintain your record like this you need to
draw the columns for -. ch month on a septate page (see simple
attached at the end of■ paper, Table II)
Parity: This means the number of times a mother has conceived before
this present pregnancy. This includes all previous term deliveries
and abortions.
eg';
Kamal a was pregnant three times before this pregnancy. She had
two normal deliveries and one abortion. Her parity will be
written like this: P2 + 1
’
P stands for parity
2 stands for previous full term deliveries
1 stands for previous abortion
Enter this in column (6)
3.
Expected date of delivery (EDD):'
Enter the EDD in column 7.
EDD is calculated like this;
Find out from the mother the date and month of her last menstrual^eriod.
Add 7 days to this and substract 3 months from this.
.For example:
Radha had her last menstrual/peripd on 10th of May 1980.
Her EDD w-ill be calculated like this:
To the date of her last menstrual^period
add 7 days
: ' May 10+7 days = May 17, 1980
Substract 3 months
: May - 3 months = February 17
EDD
: February 17, 1981.
7/
7
4.
Date of first antenatal check up:
Enter the date on which you examine a pregnant mother for the first
time. If the mother is seen and examined by you for the first time
during her second trimester, then -enter the date of examination
under Trimester II. Leave the columns Trimester I & III blank. The
information from this column will tell you how early you are able to
contact pregnant women.
5.
Tetanus Toxoid:
Enter the dates when Tetanus Toxoid was GIVEN to the mother in column 9(For the dosage schedule see paper of MCH)
This would.help you in finding out the date when the mother is due for
her next dose and you will be able to adivse her accordingly. It will
also help you in finding out how effective your tetanus toxoid coverage
is.
6.
Delivery:
When you come to know that a pregnant mother has delivered you must
visit the mother to find out the details of the delivery.
Enter these details in column 10.
All fill 1 term deliveries with vertex presentation are normal. The
other deliveries are all abnormal. See paper on MCH to find out the
various abnormal deliveries that could coccur.
7.
Still. birth/Live birth:
If a child is born dead (does not breathe at all) it is a still birth.
If the child cries after birth but dies after 2 hours it should be
recorded as a live birth in column 11. Also enter "died after 2 hours"
urtt the reason for the death in column 14.
8.
Remarks (Column 14)
In column 14, note down the date of post natal visit, condition of the
mother and the condition of the baby.
Note:
If the pregnancy results in an abortion, draw a line across all
the columns after the mother^s name and write in Remarks (column
14) "Abortion" and the date of abortion.
How to prepare a summary of maternal services for 1 year:
Total number of pregnant mothers entered
in the register from January to December
=
Total number of mothers delivered from
January to December
= B
3.
Number of abortions from January to December
=
4.
Number of mothers not yet delivered this year
= A- (B+C) = D
1.
2.
A
C
(A few mothers entered in the previous months may
not have delivered by December. These mothers,
who have still to deliver, should be entered again
under January for the next year.)
8/
5.
Percentage of mothers .overed by
Tetanus Toxoid:
-
total number of mothers delivered from
January to December
=
number of mothers who recel/ed complete
dose of tetanus toxoid
= b
percentage of mothers covered by tetanus
toxoid
—
a
b
a
x 100 = C$
6.a.Number of women contacted in 1st trimester
Number of women contacted in 2nd trimester
b.
Number of women contacted in 3rd trimester
c.
7.
Some of the other useful information you can get grom the
records:
a.
b.
c.
Percentage of normal deliveries
Percentage of deliveries conducted at home
Percentage of deliveries conducted by Dais
How to use this information:
This information would help you in evaluating your work and in
resetting objectives.
For example:
1.
If you find that the percentage of women covered
by tetanus toxoid is very low then one of your
objectives for the next year would be to find out
the reason why women are not prepared to take tetanus
toxoid. If tetanus is really a problem in the area
your objective would be to give appropriate health
education to the mothers.
2.
If you find that the majority ofthe deliveries are
conducted by Dais then one of the objectives for the
next year could be to train Ibis in conducting
aseptic deliveries
3.
If you find that many more pregnant mothers come to
you in the 3rd trimester than in the 1st and 2nd
trimester, one of your objectives for the next year
could be to'make greater efforts to contact all
pregnant women in the 1st or 2nd trimester.
OUT PATIENT SERVICES
*E
OU
PATIENT RECORDS (OPD)
Those of us who run a dispensary or village clinic already keep a record
of the patients we treat. Some of us keep more detailed OPD records than
others. Also, some of us use information from OPD records to make decisions
about our work. In the assignment of 'Analysing OPD Records' we have
already mentioned the various kinds of information that we can get £rom
such records. To remind you, from OPD records, we should be able to
find out:
9
a)
b)
c)
d)
e)
f)
g)
the diseases we have been treating
in which months we get most cases of a particular disease
how many patients come back to us with the same disease
which medicines to stock
how many patients do we get per day
distance and villages from which patients come
economic status of patients, are they males or females,
from which caste etc.
How to keep OPP Records
In table III attached at the end of this paper, we have given a
suggested sample of OPD records.
NOTE:
1.
In column 15, make a note of
a) patient referred
b) patient needing admission
c) any other important information
2.
If you are using OPD cards you could add a column to
record the OPD cumber of ®aoh patient.
How to use information from OPD Records:
1.
From Column 1, we can find out the number of people we treated,
each month, and in the full year.
Find out:
a)
b)
Question:
2.
In which
. months do we get most patients? Why?
On an average how many patients do we treat per day?
On an average how much time does our team spend in
the dispensary per day?
From column 4, we can find out the number of male and female
patients we have seen in one year.
Find out:
a)
b)
3.
Do we see more males or females?
Is this difference a big one? Why?
From column 5, we can find out the number of patients that
come to us from different caste groups (or Tribal/non-tribal) .
Find out:
a)
b)
4.
Do we get most of our patients from any particular
caste group?
If yes, why?
Do we get patients from the lower castes?
If not, why?
From column 6, we can find out the number of patients that come
to us from different villages.
Find out:
a)
b)
c)
From which villages do we get most of our patidnts?
Are these villages in our target area? If not,
why is it that patients from the target area do
not come to us?
How far are the villages from which patients come?
10/
10
5.
From column 7, we can find out the diseases we have been treating.
Find out:
a)
b)
6.
From column
How many cases of each disease have we seen in a year?
How many of these diseases are preventable?
8, we can find out which medicines we use.
Find out:
a)
7.
^hich medicines do you need to stock and in which
quantity?
From columns 9-14, we can find out the income and e'xpenditure of
the dispensary. We can also decide how much to charge a patient.
Find out:
a)
b)
*chtt: pt: 26.8. ’ 81
What is the average cost of treatment per patient ?
|
What is the average income to the dispensary per patient?
The Catholic Hospital Association of India
C. B. C. I. Centre, Goldakkhana, New Delhi - 110001
Tel. 310694, 322064
UIJD3RSTAl'!DinG COIilfOlTITY ESaLTE
.Everybody talks about community health programme and
many are carring out.
Still many want to start it.
It is good
to analise and see "why wo do community health progranae and
what we do in coramunity health programme?"
It is a well accepted
fact that 30^3 of the Indian masses live in rural areas and 20^>
in the urban area.
WHO has proclaimed health for all by 2000 AD.
According to our present situation this slogan is really a
questionmark to us, on mainly how this can be achieved?
The
existing health care system is not catering to the needs of the
rural masses.
Everyona know the defenition of WHO "that health is not
scare absence of desease but health is a state of total physical,
mental, and social well being".
Jesus said,
to give life and life in its fullness".
"I came to the world
Reflecting on this, we
realise that our health caro system is dosease oriented and not
person oriented.
Attaining this total well being demands an en-
viornment in which the basic needs are fulfilled, social well
being is ensured and psychological as well as spiritual needs
For example; Government of India made a survey in which
are met.
they found out most of the mothers and children die - due to
malnutrition, infection and uncontrolod fertility.
The methods that Government used for this did not bring
much change, because it was a target oriented programme.
We as
Christians who work according to the carism of Christ, specially
in his healing mission,
let us go deep in this findings.
have to tackle such problems.
How we
In the community or in a society
the root causes of illness lie deep in social evils and inbalances
For this the remedy is not a curative approach, but people
should be made aware of the real needs, rights and responsibili
ties and also the available resources in and around them and got
themselves organised for appropriate actions.
Through this proces;
health become a reality to the vast majority of the Indian masses.
The world counsil of churches had interviewed 6000 out
patients in
care,
India,
and found out that only 5$ needed doctors
1 5/^ by paramedicals care and another 15% had self curing
deseases; which means 80^ could have been treated in the
community.
This analysis make us to reflect that the total
-2-
health cannot ba achieved by medical solution only, but dosoases
has got a chain of causes which has to be tackled fqr the total
wellbeing, eg. diarrhoea.
Because of the many different factors that influences
nan's health and life in an interdependent and integrated way,
both as an individual and in community, community health programme
should also be an integrated efforts directed towards this.whole
life situation.
Factors related to food, housing, work, education
and general living conditions are therefore important as well as
everything that helps man with regard to his identity and dignity,
and give room for initiatives related to human development.
The new sot of parameters
Today the health status of the country is measured by
If we are working out for
infant and maternal mortality rate.
the total wellbeing of the people,
this way of measuring the
health has to be ehanged and a new set has to be used, such as
the people's part in decision making, absence of social evils in
the community, organising capacity of the people, role women and
youth play in matters of health and development etc.
So the concept of community health should be understood
as a process of enabling people to exorcise collectively their
responsibilities to maintain their health as their right and
responsibility.
Thus it is beyond mere distribution of medicines,
prevention of sickness and income generating programmes.
Health for all by 2000 AD is a realistic and feasible goal
Some conditions are however essential for success.
The attain
ment of this goal depends above all on three things.
1.
The extent to which it is possible/reduce poverty and
unequality and to spread education.
2.
The extent to which it will be possible to organise the
poor and under privileged groups.
So that they are able
to fight for their right, and,
3.
The extent to which we are able to move away from the counter
productive consumerist western model of health care and to
replace it by the alternative model based in the community.
3
These are cur tasks and it needs millions of young non and
women both within and without the health sector to work for them.
If a mass movement for this purpose can be organised and the
people rededicate themselves to the realisation of their national
goal.
The country will be able to keep its tryst with destiny
at least by 2000 AD.
COMMUNITY HEALTH DEPARTMENT
C H a I
APPENDIX
Dy CpAru.iT Oil OF ALI2A. —AXA
On 12 September 1978, at Alma-Ata inSoviet
Kazakhstan, representatives of 134 nations
agreed the terms of a solemn Declaration Ple
dging urgent action by all governments, all
health and development workers, and the world
community to protect and promote the health
of all the people of the world.
The Climax
of a major International Conference on Primary
Health Care, jointly sponsored by WHO and UNICEF
this Declaration stated;
The conference strongly reaffirms that health,
which is a state of complete physical, mental and
social wellbeing, and not merely the absence of disease or
infirmity, is a fundamental human right and that the atta
inment of the highest possible level of health is a most
important world-wide social goal whose realisation requires
the action of many other social and economic sectors in
addition to the health sector.
1,
The existing gross inequality in the health status
of the people, particularly between developed and'
developing co-uitries as well as within countries, is poli
tically, socially and economically unacceptable and is,
therefore, of common concern to all countries.
2.
3.
Economic t.nd social development, based on a New
International Economic Order, is of basic import
ance to the fullest attainment of health for all and to the
reduction of the gap between the health status of the de
veloping and developed countries.
The promotion and pro
tection of the health of the people is essential to sust
ained economic and social development and contributes to a
bettor quality of life and to world peace.
The people have the right and duty to participate
individually and collectively in the planning and
i .'.piementation of their health care.
4.
5.
Governments have a responsibility for tne health of
their people which can be fulfilled only by the pro
vision of adequate health and social measures. A main
social target of governments, international organizations
...... 2/
and the whole world community in the coming decades should
be the attainment _>y all peoples of the world by the year
2000 of a level of health that will permit them to lead a
socially and economically productive life.
Primary health
care is the key to attaining this target as part of deve
lopment in the spirit of social justice.
Primary health care is essential health care based
on practical, scientifically sound and socially
acceptable methods and technology made universally access
ible 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-deter
mination.
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 economic development
of the community.
It is the first level of contract 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.
5.
Primary health care s
1.
reflects and evoles from the economic conditions
and socio-cultural and political characteristics of the
country and its communities, and is based on the appli
cation of rhe relevant results of social, biomedical
and health services research and public health experi
ence ;
2.
addresses the main health problems in the community,
providing promotive, preventive, curative, and rehabi
litative services accordingly;
3.
includes at leasts education concerning prevailing
health problems and the methods of preventing and controling them; promotion of food supply and proper
nutrition; and adequate supply of safe water and basic
sanitation; maternal and child health care, including
family planning; immunization against the major infect
ious diseases; prevention and control of locally ende
mic diseases; appropriate treatment of common diseases
and injuries; and provision of essential drugs;
k,
involves, in addition to the health sector, all re
lated sectors and aspects of national and community de
velopment, in particular agriculture, animal husbandry,
3
food, industry, education, housing, public works, connnunications and other sectors; and demands the coordi
nated efforts of all those sectors;
5.
requires and promotes maximum community and indi
vidual 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 cafe
for all, and giving priority to those most in need;
7. relies, at local and referral levels, on health
workers, including physicians, nurses, midwives, auxi
liaries 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
All governments should formulate national policies,
strategies nd plans of action to launch anu sustain
primary health care as part of a. comprehensive national
health system and in coordination with other sectors.
To
this end, it will be necessary to exercise political will,
to mobilise the country's resources and to use available
external resources rationally.
8.
All countries should cooperate in a spirit of part
nership and service to ensure primary health care
for all people since the attainment of health by people in
any one’country directly concerns and benefits every other
country.
In this context the joint "/HO/UITICSF report on
primary health care constitutes a solid b;,sis for the fur
ther d evelopment and operation of primary health care throu
ghout the world.
9.
An acceptable level of health for all the people
of the world by the year 2000 can be attained
through a fuller and better use of the world's resources,
a considerable part of which is now spent on armaments and
military conflicts.
A genuine policy of independence, peace
detente and disarmament could and should release additional
resources that could well be devoted to peaceful aims and
in particular to the acceleration of social and economic
10.
development of which primary health care, 'as an essential
part, should be allotted its proper share,
The International Conference on Primary Health Care calls
for urgent and effective national and international action
to develop and implement primary health care throughout
the world and particularly in developing countries in a
spirit of technical cooperation and in keeping with a
New International Economic Order.
It urges governments,
VJHO and UNICEF, and other international organizations,
as well as multilateral and bilateral agencies, non-gov
ernmental organizations, funding agencies all health
workers and the whole world community to support national
and international commitment to primary health care and to
channel increased technical and financial support to it,
particularly in developing countries.
The Conference calls
on all the aforementioned to collaborate in introducing,
developing and maintaining primary health care in accord
ance with the spirit and content of this Declaration.
The Catholic Hospital Association of India
C. B. C. I. Centre, Goldakkhana, New Delhi - 110001
Tel. 310694, 322064
0 R G.A » I. Z.. I _N G
THE.
0. 0, M M U N IT Y
All of us art familiar with the saying, "Strength lies
in numbers" . We have heard it often and most of us have seen
or experienced the truth of this saying in our own lives, We
may have seen a group of city dwellers protesting against corru
ption in the municipal corporation. We may have seen or read
about a group of tribals demanding a just redistribution of govt.
lands. Whatever be the case, a well organized group of people
can achieve more longstanding results than single individuals.
This is because of the p,ower they have as a group.
In this paper we shall discuss in more detail why we
must help the community to organise- and some guidelines about
how to do this. V/e will also discuss some of the problems in
organizing the community.
1 .
iinity_ there i.s__strength .
An organised group increases the solidarity, spirit of
cooperation and self confidence amongst the members. A group
also'provides courage and support to its members to face situations
that arise while solving the community's problems. It encourages
sharing in the community by distributing work, responsibilites
and benefits among the members of the group.
2 .
Mob 1i li z i ng__ re sources
An organized group can more successfully get together the
resources available in the community for a specific activity. For
example, getting the village together for a sanitation drive will
be more successful if the members of a Mahila Mandal or Youth Club
take the responsiblity for it. Raising the resources in cash or
kind from the community for an activity can also be done more
effectively by the members of such groups.
3 ;
Sy_ste ma tic _p^Lanning.
Organization enables people to plan systematically for
collective action in meeting their basic needs such as food, housin
health etc. In order to bccone strong and tackle the community's
problems, the community must be organized. Regular meetings, an
enthusiastic leadership, meaningful short term activities - all
these hc-lp the group to realise its potential and to undertake more
difficult long-term activitcs to solve their basic needs.
Thus building up groups in the community is an effective
way of strengthening people's participation ih development prog
ramme s .
HOW TO ORGANIZE THE COMMUNITY
The effectiveness of a group depends on a number of things
such as the satisfaction it provides to its members, the type of
leadership within the group etc. Therefore it is important for us
to keep certain points in mind when organizing groups in community,
namely :
2/-
2
1.
'M.*Interest
W
We can organize a community on the basis of different
factors; for example we can form a Mahila Samiti or Women's group.
A young farmer's club would bring together farmers with land.
low income’landless labourers can be brought together as a group.
Whatever the group, we must remember that people will make the
effort to xkx form a group, if they think they will benefit from
it. Individuals come together to satisfy a personal interest
(monetary, emotional, mental, social etc.) This principle can
help us intwo ways.
(a) We must be clear about our goals - why and shorn we want
to organize in the community. If only 25% of the people in the
village have land we cannot expect everyone to be interested in a
farmer's club. Only few people with land will be interested in
forming such a group. This can lead to a more unhealthy situation
in the village. On the other hand a farmer's association can do
a lot of good in a village in which more than 90% of the families
have at least 2-3 acres each.
(b) A group becomes attractive to its members, only if it
satisfies their needs. For example, a farmer's association might
show a lot of enthusiasm in attending classes on dry farming
<
methods. The same group of farmers may show no interest in learning
to read and write, as they may not see this as a need.
2 .
Knowing_ the_ Community
Before organizing groups in the community, we must get to
know the people well, understand their problems, customs and
traditions. We must give the community time to understand our
motives. We must also find out whether there are already some
groups functioning in the village before starting new ones. For
example, there may be a youth group already in the village which
will now- has only been undertaking cultural functions on festival
days. In this case there may be no need to organize another youth
club. Instead we could get to know' better, the functioning of
the existing Youth Club and slowly try and build up this group by
introducing fresh ideas into the group eg. literacy classes,
sillagc sanitation etc.
3 •
Slow process
The process of organizing and building up groups in the
village is a slow one. We cannot expect the people to be enthusi
astic about our ideas on organization since they may not be sure
of what they are going to get involved in. It is always better to
go slow. For example, if we feel that a Mahila Mandal could, be
very useful in our village then we may have to meet the women in a
series of informal
therings, individually and in small groups.
During these meetings, we could introduce the ideas of a regular
Mahila Manda.l and the different typos of activiites that a Mahila
Mandal could undertake. T'he women will accept the ideas only if
they feel that this will be of some value to them. This may take
more or less time according to the confidence the women place is
us, our rapport with them, their own needs etc.
4•
Administration
Organization means that things are done in an ordered way.
Meetings should take- place at regular intervals to take decisions
and to see that these arc carried out. xvecords should be kept of
the decisions taken. These records should be read out at the next
. ting .
. 3 /•■
3
-
to bring all the members up to date on all that has happend.
so far .
- to see if those responsible have done their tasks.
Tasks should be divided between different people, ihe tendency of
giving responsibility to the same people every time, should be
avoided.
Care should be taken to handle all financial resources of the
group carefully. Everybody should know how much money has been
collected, on what it has spent, how much remains and what is done
with it. Simple but careful accounting is necessary for this. If
there is no control over the collection and use of money then
things may go wrong. This may also happen if the matter is left
entirely to one or two individuals. Accounts should be checked
on a regular basis, however small the total amount is.
REMEMBER : The group will be highly motivated to continue as a
group if
- they feel the group is their own
- if everyone participates in decision making.
PROBLEMS IN ORGANIZING GROUPS
Organizing groups inthe cpmmunity may create certain problems
depending on the type of group, our rapport with the people, the
type of leadership provided by us etc. Some of these problems
which we must be aware of arc discussed below.
1 •
Handling conflict situations within a_..g.r oup,, a n_d, between .groups.
In Chakrapur village, the project staff had organized a Young
Farmers Club which got into a series og quarrels with the VHW of
the villager The staff of the project were aware of the situation
but did not take any action until things reached a very serious
point. Our role in handling such conflict situations is very
important. We must
(a) be alert to pick up and the help resolve such conflicts
before matters become very unpleasant.
(b) be impartial in our judgements and behaviour towards
individuals and groups in the community, It is also import
ant to note that all major quarrels (regarding development
programmes) in a village are best resolved along with the
community and project staff.
(c) be constantly aware of and emphasize the common interest
with which the group has become together, ^'he groups should
take up activities which will strengthen common bonds rather
than high light their differences.
2•
Short
_si£h t edne_sj.
In a particular village in Gujarat, a group of development
workers organized a buffalo cooperative for small farmers. These
farmers had a little land to their own. However they depended
heavily on the landlords for work specially during the harvest
season. Each of these farmers had one or two buffaloes but were
forced to sell their milk at very low rates to the landlord who
would sell all the milk in the nearest big town at a high rate.
By organizing a buffalo cooperative the development workers were
- 4 able to help in the marketing of the milk and in getting higher
prices. The landlord was thus eliminated, as the middleman. This
was obviously unacceptable to the landlord, who eventually
threatened to get labour from the next village during the coming
harvest
It is important for us to beaware that such serious problems
in the community can be created by our short sighted attempts to
organise groups. This is especially true when we organize groups
around economic issues like wages etc. where the interests of
another group in the community are threatened. Therefore, unless
we are prepared to handle such conflict situations and are aware
of the repercussion on the community of such an action we shoud
be cautious in our approach.
3•
Outside aid
Insisting pressures from within the community and from
within ourselves to get aid from outside for the group activities
is a major problem. The ease with which financial assistance is
available from funding agencies often prevents us from allowing
the members to persevere in their efforts to collect money for
small activities. Barely is a Mahila Mandal formed and a decision
to start a savings scheme or small goat scheme taken when the
pressure to get immediate funds from an agency throws us into a
dilemma. Should we or shouldn't we use outside resources for say
a Youth Club activities ? This is a difficult question for which
no definite answers are possible. It is important to remember
however, that it is easy to destroy the group’s intiative in under
taking their activities if easy money is available from outside.4-•
Keeping up_ the group interest
One of the mjor problems often encountered by organizers is
that they find it difficult to keep the interest of the members of
a group alive after a period of time. One of the questions often
asked is "how do we sustain the interest of the members of (say)
our Mahila Mandal ?" It is natural that people will not be able
to participate fully in the groups activities during busy agri
cultural seasons such as sowing and harvesting. This is not a
cause of worry. On the other hand when there us a seriets lack
of interest and continued low atteneance at meetings we must
take a second look at the Mandal's activities. Wc have often seen
Manila's formed by cnthusaistic women coming together for sewing
classes .soon becoming smaller and smaller because further classes
on bead-bag making etc., do not seem to interest the women despite
repeated, requests to come. In these casss it is obvious that the
woman were enthusiastic upto the point that they learned to stich
their own clothes and a few clothes for their own children. They
were uninterested in bead bags because
(a) they could not afford the raw materials.
(b) they found it difficult to sell these in the local market.
Most of these women were quite poor and were keen to
increase their income by producing som saleable sjuff eg. pickles,
papads etc. These income generating programmes can be started in
a small way, producing goods for the local market. Other small
activities like savings schemes, goat schemes etc. can also be
taken up.
.. 5 ..
5
Whatever the activities, the basic principle to remember is
the one first mentioned in the previous section i.e. individuals
will come together to satisfy a personal interest. When people
feel that they arc wasting their time in the group then th^y lose
interest ans soon drop out.
To_ Summarize :
We have seen that building up groups in the community is one of
the effective ways of mobilizing people's participation in the
development process. Wc must get to know the community and be clear
about our goals before organizing groups. We have also discussed
some of the problems that could arise when we undertake this acti
vity. It id important h. re to remember that organizing against
vested interest in the community can lead to a serious situation
and both the community and we nedd to be specially prepared to
handle such situations.
Prepared by
Voluntary Health Association of India
C - 14s Community Centre,
S.D.A., New Delhi - 110016.
chtt/la/29-2-1984
The Catholic Hospital Association of India
C. B. C. I. Centre, Goldakkhana, New Delhi - 110001
Tel. 310694, 322064
INVOLVING- LOCAL LEADERS
In the workshop, we have often discussed the importance of invol
ving local leaders in our Community Health Programme. Let us
briefly review who these leaders are, why it is important to
involve them in our programme and how to recognize them in the
community.
WHO ARE LEADERS?
There are two kinds of leaders- formal and informal leaders.
Formal leaders are persons who have been appointed or elected
to fulfil certain administrative responsibilities for the whole
village. They hold a recognised post and may or may not be
paid for it.
Examples^
(i)
Sarpanch, Panchayat Members, Tehsildars or
Revenue Collector etc. These leaders are part
of the government's administrative structure.
(ii)
In certain tribal areas each village ma,y elect
its own headman and committee members to help
the headman. These may or may not be a part
of the government structure.
Informal leaders are people whom the community respects and
trusts. People go to such leaders when they have a problem
or need advice.
Examples’
- The people may go to the pujari for all religious
matter s
- The people may take the opinion of certain village
leaders when there is a family dispute
- The people may goto the faith healer (Bhuva, Badwa)
when there is some illness in the family
- The people would take the advice of the dai in
matters related to pregnancy and child birth
It is thus clear from the above that informal leaders have a lot
of influence in all important matters in the community. The
people look upon them as knowledgeable and having a sound
judgement.
WHY SHOULD WE INVOLVE ALL THESE LEADERS El Ol!R PROGRAMMES?
Both formal and informal leaders have a lot of power in the
community and are able to influence the decisions of the people.
In some cases people simply follow a trusted leader, in others,
leaders can get people to participate in an activity by creating
awarene ss.
leaders arealso capable of forcibly getting the participation
of the people by threats and in extre qe cases by actual violence.
It is important for us to work with both kinds of leaders.
Formal leaders may or may not have (Eg J Vishalnagar Case) the
trust of the community. But it is important that they be
informed of, and if possible involved in all our activities
because these leaders are usually the most powerful in that
they could have a strong economic hold on the people.
..2/-
2
Informal leaders, on the other hand, may be more trusted by the
community and can be of great help to us if their cooperation is
sought. They can also influence the community against our
work if their involvement is not sought.
let us now look at some of the ways in which local leaders can
help or hinder our work.
1 .
Gaining the trust of the people
When we enter the community as outsiders it is natural that
the people may question and be suspicious of our motives.
Here, if the local leaders, especially the informal leaders,
understand our reasons for wanting to work with the community
they can help us to gain acceptance with the people. This
way, they will also help us get more information about the
people, finding out the needs of the community etc.
- A Team of Health Workers wanted to start a Leprosy
Control Programme and cover a whole block. All the
team members were new in the area. At first, the people
of the nearby villages looked at them with distrust.
The team, realising that they needed the trust of the
people to achieve the aim of their programme, made
an effort to contact all the village Sarpanches of
the block before starting their work. They also tried
to find out who were the influential people in the
most important villages, started to befriend them and,
in the process explained their reasons to be there
and what they expected to achieve. In no time the
team felt that people started to look at them in a
different way and came forward to help the programme.
One of the most important local informal leaders became
a strong supporter of the programme, considering himself
as part of the team and helping them in their numerous
difficulties.
2.
Help in specific activities
There are many ways by which local leaders can help us in
our activities. They can be very helpful in planning and
implementing all our programmes. For example, they can be
most useful in involving the community in collecting
information for the baseline survey, getting the community
to decide on a particular plan of action and in helping
to evaluate the success of our programmes. Leaders can
help to raise resources from the community for programmes
and can take on a great deal of responsibility to see that
programmes are run smoothly.
- A group of health workers in a tribal area had been
doing health and development work for 3 years. They
had built up a good relationship with the people
during this time. In the third year, a severe drought
occured in the area and a funding agency gave them
funds for a drought relief programme. The money was
used to buy seeds which did not require much water
to grow.
A committee of 4 persons chosen by each village took
the responsibility for-the proper implementation of
the scheme in each of their villages. Within two
days the committees had drawn up an impartial and
..5/-
3
accurate list of beneficiaries with their land
holdings and the quantity of seeds required by
each. The committee members along with the health
workers purchased the seeds. The distribution
was done in a systematic manner and proper records
w~re maintained by each committee. Twenty five
villages (with 900 families) benefitted from this
programme.
Just as local leaders can be a great help, not involving
then can also hurt our programme. We have seen that
their support can help us gain community acceptance and
participation. Several case studies which we have discussed
in the workshop have shown the harmful effects of non
acceptance by the community. However, it is important
for us to take into account the various factors in a
village situation and not be completely taken in by
whatever a leader says ( remember the case study Hidden Motives).
HOW TO RECOGNIZE INFLUENTIAL LEADERS?
In your visits to the village, you will probably find
that certain people's names are often mentioned in answer
to questions like!
1.
2.
3.
4.
5.
6.
Who are the important people in the village?
Whose opinion do you respect?
Whose advice do you follow?
Who settles arguments within or in between families?
When there is an illness in the family, whom do
you go to?
Who are the first persons to do something when
there is serious trouble in the village?
These people whose names you hear often are probably those
with leadership qualities and respected by the community.
You must remember that you must ask the above and related
questions in different sections of the village otherwise you
may not get a complete picture. Thus, in a village with
different caste groups it is most likely that each caste
group has its own elders and leaders who influence that
caste group more than the leaders belonging to the other
groups. This is an important point for you to remember.
Keeping ones ears and eyes open i.e. by listening and obser
ving people, events, situations, during village visits, you
can identify informal leaders and also check bho information
you have on individual leaders.
- In a village of south India, a team of health workers
identified very quickly the formal leaders. It was
also easy for them to find out the informal Caste
leaders. But it took them several years to realise
that the Hari.jans of the village had great trust
in one of their young men and that, in fact this
young man was one of the most powerful leaders of
the Harijans. This fact came to light when the
Harijan colony was burnt down and help had to be
organised to rebuilt it. He was the only one who
could control the grief of the people and encourage
them to rebuild the colony altogether, those who
had not suffered from the fire helping those who
had lost everything.
..4/-
4
TO SUMMARIZE :
We have seen that it is important to involve local leaders
in our Community Health Programme because they are powerful
and can make decisions that result in the success or failure
of a programme. Community participation, so essential for
the success of our programmes, is usually decided by the
community leaders.
***************
Prepared by:
cntt:rrJ 29.3.84
Community Health Team
Voluntary Health Association of India
C-14, Oomnunity Centre, S D A
New Delhi-110 016
<
The Catholic Hospital Association of India
w
C. B. C. I. Centre, Goldakkhana, New Delhi - 110001
Tel. 310694, 322064
WHAT DO YOU NEED TO THINK OF BEFORE
PLANNING A COMrlUiriTY HEALTH PROGRAMME
1 • introduction
Resources available for Health Programmes are generally limited.
It is, therefore, important to make the best use of these limited
resources.
It is now accepted by all that one of the best ways
to improve the health status of the people, within the limited
resources available, is by good Community Health Programmes.
The principles on which Community Health Programmes a re based
have already been discussed and all of us now accept that such
programmes
- require an integrated approach to the solution of
the community’s numerous problems
- need the full participation of the Community in
solving these problems
- and that people’s participation should mean full'
involvement in the different phases of the programmes.
Health has a different meaning for different people.
For the
majority of professional health personnel (Doctors-NursesParamedical Workers etc.) the meaning of health is generally
restricted to absence of diseases.
Still, in our country the
majority of people have more urgent problems to face in their
daily life and all these problems have a strong influence on
their health.
They are food - drinking water - sickness - edu
cation - unemployment - shelter and clothing - social and
cultural acceptance.' Tf such is the case, before starting to
develop a Community Health Programme, wo will have to be well
informed on the peqpe’s problems in the area where, the programme
is to be implemented, the already existing facilities for meet
ing these problems, and the available resources which can be
used for community development programmes.
When planning, a few points must be kept in mind: The projected
programme should
- be planned in full collaboration with the community
- be based on actual and felt need of the community
- be realistically planned
- as far as(possible make use of locally available
re sources•
11 • CHOICE of an area
(target area)
As a rule you are already attached to a base institution,
either a dispensary, health centre or hospital.
This institut
ion's broad objective is to improve, in one way op? another, the
health status of the population living around it. Thus the target
area where you would normally start a Community Health Programme
is already fairly well defined.
But even then, you will have to select more specifically
whether you have to start in villages situated north, south,
east or west of the base institution, which villages to select
how many villages to start with etc.
2
Probably you know the villages around your base institution
very well. You know how they live, how poor they are. You also
kiibw that there are no medical facilities available, except
your institution, nor is there any help of any typo nearby.
Well, try to put on paper all the general information we are
suggesting you get and realise how much you really know.
To helr> you in your selection we suggest the following steps;
1. Study the location of your institution and of the area arount it:
a.
Make a good map of area covering about 15 to 20 Km around
your institution.
Oh the map, locate state-districts~block
divisions boundaries, all villages, roads, rivers existing
health facilities and any other informations you would
find useful
*
b.
Make a list of all the villages situated on the map with
their-population as per the latest census.
Census are made every'ten years.
The latest one is just
being completed(19^1 ).
In case the■census has been done
several years ago and you want to have an approximate
correct figure of the population^ you can calculate it as
follows :
Population as per last.census +(Population as per. last
census x 2
5
*
x Number of years )
100
«=. approximate correct population
The. increase... of .^the population is calculated on-the average
increase of the .population in..India.:. 2,
5%
*
per year.
So, if
... a. village--is-said to. have a population of 2,500. in the last
. . survey and you want to know it s* correct '.‘approximate popu
lation 6 years, after completion of the survey you can.
easily find it this way:
2,500- +(.2,500 X 2.5 x 6) « 2,875
100
.
A
-c». Find out under which block development tho village -situated
on the map belong.
If you do not have a good map you can easily under or over
estimate distances, you may think a village is only 2 Km from
your institution and it appears so on a ma p where roads and
path have not been situated.
But when you decide to visit
that "nearby" village, you realise that you have to walk
around a big water reservoir and it takes you more than one
hour to do so’.
- A para medical worker had to visit a village, which, on
the map appeared to be 3 miles'.from the base centre and
he decided to go there cycling.
To his dismay, the road
which he thought was good all the way., turned out to "be
a foot path after only one mile from the base centre.
This foot path was following the boundaries, of flooded
paddy fields and twisted in all directions. Because of
this he had to carry his cycle for most of the remaining
journey and the distance'was much more than tho three nilas
he had expected it to be. In fact, it took him two hours
to reach the village and how -tired he was after reaching
it!
3
- i ll" go *
.-wn
oj^nn..«.- ■bo.ns very
and OO VO would
decide that it is' not worth concentrating our efforts on it.
BuftKo pop>ulation of this village, is, according the latest
census, above 1,000.
How can that bo?
j\
The reason is very simples
We probably saw only one of the
several hamlets of the village!
This is a very common happ
ening mainly in a tribal areas where hamlets of a same village
are sometimes far away from each other.
- In Bihar, during the drought relief work, a team of
health workers used to visit weekly a small village.
According to their estimate this village had only
about 30 houses and all of them were inhabitated by
non tribal Hindus.
After three months, the workers missed the small path
they usually took and, after asking the direction of
the village from Tribals working in the nearby fields,
they were shown another path which would take them
to the same village.
When reaching the place indicated to then^s the village,
the workers could not recognise it.
More over, they
were in a Tribal village, so it had to be a different
one from the one they used to visit!
But when talking with the village people they were
told "no, you are in the right village".
How can
this be? This village had, in fact, four hamlets se
parated from each other by about 3 to 4 furlongs.
Communities of these hamlets were all differents
Tribals - Muslims - Hindus - Christians.
Up to then, the workers had only visited the Hindu
hamlot of the village and the people of this hamlet
carefully avoided talking about the other hamlets of
the villages
For all that the health workers knew
this hamlet was the village!
If a targec area chosen by a Health Centre is situated in
a different block than the one in which the health centre
is situated this has to be known.Why?
- A group of workers have a community development pro
gramme in an area covering 20 small villages.
Their
Block Development Office is only 6 miles from their own
centre and they have good rapport with the Block Deve
lopment Officer.
Still they cannot obtain help from
the BDO for the villages of their target area.
All of
them are situated in a block different from the one
where the Health Centro is.
2.
Study the Communication system in the areas
Is
a.
there a railway communication system in the area? If
yes, how is it? How frequent are the trains, where do
they go, what villages and towns do they link together?
How
b.
is the. bus system in the area? Where do they go?
How often? Which villages can you reach by bus?
What
c.
is the condition of the roads leading to the different
villages of the area?
Are some of them blocked by water
during the rainy season?
Which ones? How long would the
villages be isolated from the base centre?
Are
d.
t.iere short-cuts allowing communication between
villages through the fields?
Are these short-cuts easy
4
to walk? What would be the distance between two villages
linked by short-cuts?
To know the conditions of roads in all seasons is important.
A village with a Community Health Programme needs constant
and regular contact with the base centre.
- One centre planned a Medical Extension Programme and
applied to a donor agency for funds.
In the application
they requested a vehicle to visit three centres bi-weekly,
recurring cost of the vehicle and salaries for two full
time workers.
The proposal seemed interesting and thus
the donor agency sent a person to study the proposal, with
the centro.
Surprisingly, the three villages were found
to have roads which would be cut during the rainy season,
and there, the rainy season lasts for 5 months!
This fact had been over looked by the planners!
To know the timing of the buses when we go to villages can
become very important.
- People of a village situated about 10 miles from a dis
pensary were very keen to have a nurse of the dispensary
visit their village regularly.
They insisted so much
that the nurse, though very busy, decided to go.
But she
would have to go by bus as the dispensary had no vehicle.
No problem, said the people, we have many buses between
here and the village.
There is a very good one leaving
this dispensary at 8 a.m., so why don't you take it?"
She did take it and spent a fruitful busy day in the
village.
But when she wanted to come back, she discovered
that the bus which took her in the morning was the only
one going back in the direction of the dispensary, and of
course it had left hours ago.
She then had to walk for
more than one hour before she could reach another village
where a bus going to her dispensary would pass through
sometime in the evening... She waited in that village
for more than 2 hours before seeing the famous bus come.
3• Get information on the Socio-Cultural-Economic condition
OF the area (from Govt, sources”)-
a. What is the density of the population?
b. What is the general pattern of agriculture in the area?
Is land irrigated? by what means is it irrigated?
What type of crops is grown on the land? How many crops
per year?
c. How big is land holding per family? (average)
How many families have small land holding (percentage)
How many families are landless? (percentage)
d. Is there industry in the area? If yes, how many workers
are employed in them?
e. What is the average daily wage of unqualified labourer?
f. What are the main communities in the area (percentage)?
Our effort should reach the greatest number of people.
It is
therefore important for us to know the density of the popu
lation in our area as well as the approximate population of
the villages, before we finalise our plans.
- One group of workers decided that the area most in need
of their help was situated in the north of their base
centre and thus they were ready to select it as the tar
get area of their Community Health Programme.
The rea
son for this choice was that very few patients were
coming from there, but thos who come were all very ill.
There was, therefore, a need for better contact between
the base centro and the population of the villages
situated in that area.
But when studying the density
of the population and the socio-economic situation of
that area, it came out that there were in fact few vi
llages there as it was a jungle area.
The villages
were small, far away from each other, isolated.
A pro
gramme there would, have benefitted very few people and
would have been difficult to i. plement.
3ut in the oast of the base centre, there was an area
with several fairly big villages, so would it not be
bettor to select the east are first as a target area?
The workers of the centre who had almost decided to
select the villages situated in the east of their
base centre, considered the other villages located in
south and west of their base centre.
They then rea
lised that the villages located in the oast of the
centre had their field well irrigated by a big water
tank.
They had an average of two to three crops per
year.
On the contrary, villages situated in the south
and the west had no irrigation facilities of any type.
The villages of these areas were considerably smaller
than in the villages loct.ted i.i the east, but the need
of the people was much greater.
Our effort should benefit the people really in need of help.
It is therefore important for us to know about economic con
ditions of the area where our centre is situated and of the
villages situated in it.
Economic situation will differ
from village to village, but as a rule some areas can be
demarcated as poor, fairly poor or well off.
4■ Study all the existing facilities Jun th e. area
a. Has each village of the area an elementary school?
'/here are the middle and high schools?
Are there any colleges in the area? Are ther any tech
nical schools?
b. Which villages have people's associations? (liahila
Mandal, Youth Clubs etc.)
c. WhSre is the Pri: ary Health Centre?
Where are the sub
centres? Are there any government dispensary in the
area? Where? Are there any specialised health programmes,
such as Leprosy Control Units, in the area? What are do
they cover?
Are there any private dispensaries and
doctors in the area? Where are they?
d. Where is the nearest hospital? How far is it from your base
centre? How do the people go there?
What facilities are
available there (lJumber of beds, O.T. etc.)
These facilities have to be studied village wise.
This is
important for you to know because people in villages with
more facilities may have a better awareness of the need
x or change«
One important study to oe made by you is the already existing
health facilities in the area.
If you plan a small programme,
covering 2 or 4 villages only, you can easily obtain infor
mation on government activities ir/the area from the Primary
Health Centre.
You should establish good rapport with the
Pri .ary Health Centre's staff and inquire where are their
sub centres, where the other government dispensaries, how are
they staffed, what area do they cover, what "work do they do.
If you plan a bigger program.e or a specialised programme you
should contact the district health authorities or even the
6/
:
6
state health authorities before you start and find out
from them if and how your services are welcome.
This
is mainly important in the case of a specialised progra
mme such as a leprosy control programme.
Be careful
whom you contact in government circle: Contact the right
person at the right level.
- A team of voluntary health workers specialised in
leprosy started a Leprosy Control Programme in a
defined area.
It developed well and became a very
good Leprosy Control Programme.
Three years later,
to the surprise of the health workers who started
the program ie, the government opened another Leprosy
Control Programme in the area already covered by
the voluntary health workers's programme.
What a waste!
Why did the government duplicate the
work of these voluntary workers?
The answer is
simple:
The voluntary workers omitted to contact
the government authorities, in this case, the District
Leprosy Officer.
It is also important for you to be well aware of other
private health institutions in the area and of the
different types of programme done by them, so as not to
duplicate services.
III. WHERE TO FIND INFORMATION
In the previous chapter we have suggested that you
collect general information on the area where you
eventually would start a community health programme.
Most of the information we asked you to gather can
easily be obtained from:
1• The District Level:
The district map, the list of primary health
centres and their sub-centres, as well as the
description of the different programmes attached
to them, can be obtained from the District Health
Officer. He can also let you know what type of
help his department can eventually give to your
programme and what future plans the government
has for your area.
This list of the hospitals in the district, with
their facilities and staffing pattern, can be
obtained from the District Medical Officer.
In some states, the DHO and the DMO's functions
are held by one person only.
You will have to
find out how it is in your own district.
Specialised programmes, such as Leprosy Control
Programme - TB Control Programme - Family Planning
Programme have sometimes a separate person in
charge at the district level.
If you want to know
more about these programmes you will have to con
tact the person in charge at the district level,
for example, The District TB Officer.
: 7
2•
:
Block Level:
The map of the block, the list of the villages
with their population as per the last census book,
the land holding pattern - village wise, the govern
ment scheme for agricultural - animal husbandry cottage industry development can be obtained from
the Block Development Officer.
He can also tell
you what kind of help is available for the villages
through his department.
Information on the health scheme in the block must
be obtained from the Primary Health Centre, of the
block.
The doctor in charge can give you informa
tion on the sub centres attached to his PHC and
on all the Programmes going on from the PHC.
3•The District Census Book:
Every ten years, the government has a complete
census of the population done all over the country.
A book, giving the result of the census, is publis
hed for each district.
Much information is available
in this book such as: villages and their population,
percentage of literacy, landholding per village, de
velopment of local industry, landless workers, unem
ployed workers etc.
Generally the district census
book gives small maps of each block of the district.
TV •
STAPP REQUIRED FOR fx COMMUNITY HEALTH PROGRAMME
The professional staff required for a Community Health
Programme will naturally differ according to the size
of the programs and the type of area the programme has
to cover.
For example, if the programme is to be in a
forest area, there will be need for more staff for the
same population than if it were to be in a plain.
In
the forest area the villages are generally much smaller
and more scattered than in the plain, and the communi
cation system would be poor.
For an approximate population of 5,000 the following
professional staffing pattern can be considered as
adequate:
2 full-time health workers and a doctor who is willing
to assume the medical responsibility of the programme.
The two full time workers have to be well chosen, and
the qualifications will have to be according to the
activities of the programme.
In a Community Health
Programme, where an integrated approach of community
problem is accepted, we would advise the following:
1. To meet the health needs of the women of child
bearing age and of the under five children:
1 ANM or Nurse.
She would be in charge of thq/nother and child pro
gramme; pre-natal care - home deliveries - post natal
care - follow up of under five children including
immunization programme - nutrition - health check up.
Shs would deal with other priorities of the programme
for that group, such as family welfare programme.
2. To animate the community, organise people's commi
ttees and associations: one male Social Worker
(Community Organizer).
. . .8/
It will be easier for a man to relate to the men
of community and to attend, villag-e meetings which
generally are held at night.
The social worker
does not have to be a graduate.
He must be some
one who can listen, understand and work with
village people.
It is preferable to have, for
this work, someone who belongs to the area.
The professional staff will try to motivate the community
so that people participate in the different activities of
the programme.
One example of such participation is the
VILLAGE HEALTH WORKERS.
In many programmes, the person
considered as the Basic Health Worker is a person from
the community, trained by the professional staff, to meet
the basic health needs of the community.
The VHWs are
very useful, if well trained and well supported by the
professional health workers.
Generally the ANM or Nurse
would be in charge of the VHWs' training and supervision.
For some of you, this staffing pattern will seem impossible
to have.
Do not get discouraged.
Start with, a smaller
area.
Generally a small dispensary would have two persons
working there.
If you organise the timing of your dispen
sary it would then be possible for you to have a community
health programme in 2 or 3 villages to start with.
Once
the programme gets well under way, it will probably be
possible for you to expand your programme to cover 5 or 6
villages.
V.
EXPENDITURES TO BE FORESEEN AND HOW TO MEET THEM
Community Health Programmes, unless attached to a hos
pital with a fairly good income, are generally deficit
programmes.
People of the villages will certainly be
ready to meet most of the expenses, if we work out
the programme with them.
But some expenses would just
be too much for them.
So when planning a programme
we must be very much aware of one important fact.
RESOURCES BEING VERY LIMITED, WE MUST MAKE THE BEST
OF THEM.
Yes, resources are limited, and the expenses of the
programme should be, as far fas possible met by the be
neficiaries.
Therefore, we must carefully work out
our budget so that most of it can be met by the people.
What will we have to think of as expenditure? At the
planning time they can be of two types, namely:
1. Non-recurring expenses
2. Recurring expenses
1.Ncn-recurlng expenses:
These are expenses which will occur once only.
For
example, you think that to reach the villages of
your programme you should need three cycles.
The
cycles will have to be bought at the beginning of
the programme only.
So in non-recurring expenses
could be: buildings if any
equipment and furniture
vehicle if required: car -motor cycle - cycle
educational material
When planning a Community Health Programme, to be
attached to an already existing centre, the non
recurring expenses will be very limited.
9/
9
2. ~tecjrrin^ expenses:
These are expenses which will have to be met every year.
For example, the salary of the workers.
The expenses
you will have to think of will be:
salaries of the workers
- drugs for primary level of health care
in villages and- immunizations
- vehicle expenses.
Salaries of the workers is generally the main item.
In
a case where there are two full time progessional
workers for 5,000 people, the salaries will come easily
up to Rs. 1,000 per month.
N.B.: When planning a Community Health Programme and
preparing its budget you must remember that
resources are very limited and, because of this
examine carefully whether the community and you
will be able to meet the amount of expenditures
you are budgeting.
We would like you to pay particular attention
to two instances:
a• Recurring cost of a vehicle:
Many small health centres feel the need for a
vehicle and this is understandable because of
poor communication system in the area where
they are situated.
Donor agencies would gene
rally be ready to donate a vehicle to deserving
cases, but the maintenance of the vehicle will
have to be met by the health centre and this is
very high.
It will normally include:
- cost of petrol of diesel oil
- cost of taxes and insurance policies
- cost of maintenance and minor repair
of the vehicle
- salary of tho driver.
Beside this, you will have to foresee a depre
ciation of 20$ per year on tho price you origi
nally paid for the vehicle so that, after five
years, the vehicle can be replaced.
In many cases a small health centre would not
have such a big Community Health Programme and
thus the expenses of the vehicle cannot be ex
pected to be met by the people.
Can your Centre
afford this expense year after year?
b.
Stipends of Village Health Workers:
Some health centres, who have Village Health
Workers in their Community Health Programme,
want these VHWs to be given a fairly substan
tial stipend.
This principle is good, as it
is a kind of recognition given to the VHWs for
their service.
But how to pay them, how much
to pay them and who should pay them?
These questions have to be well looked into
before staj’tijjg.
....10/
10
Once, where VHWs were part of the programme, the
Programme Director decided to pay the VHWs to
Rs. 50 each.
The VIT.fs were serving very small
villages of about 200 people each.
The community
was unable to meet the expenses of the VHWs sti
pends and thus the programme started paying them.
After 6 months the donor agency who financed the
programme stopped their grant and the project
director was unable to meet this expenses.
He
stopped paying the VHWs.
You can easily imagine
what happened.
Can't you?
We said earlier, that resources are limited.
That is all
right, but where are resources available to maintain a
Community Health Programme? Whore to look for them?
a.
In the co;nmunity to be helped by the programme:
There you will find people with different skillscraft, you will find raw material, land, animals
houses, food, money.
People are poor, so how can we ask money or food
from them?
Many of you will certainly think that
way, and it is true, people are poor.
But, are
all the people poor in the villages?
Far from it,
So would it be so difficult to raise fund from the
people?
This will depend how you will work out
your programme.
People, as a rule, are much more
understanding than we credit them to be.
They.
understand that service is expensive and expenses
have to be met by some one.
In one instance, a group or workers were planning
to start a small first aid dispensary in village.
They also wanted to attach to it a good mother
and child programme.
The programme was discussed
with the people who were very interested it it.
The expenses of the programme was also discussed.
The people worked out an approximate budget for
the programme and ways to meet the expenses. They
fixed what should be the service cost so that the
workers would have enough to live on.
In another case, the workers discussed with the
people before starting a Community Health Programme
in the village.
The workers requested the village
to be ready to give them accommodation, meet the
cost of the bus for them to come to the village
and cost of drugs when it would be required.
The
people of the village agreed and so the workers
started visiting the village twice a week and
spent the night there.
They were very surprised
when the first day they went to the village food
was also provided t.o them by the people.
This
had not been asked for because this village was
very poor.
During the three years of intensive
programme in this village, the people met most of
the expenses of the programme themselves.
The
only expenses they could not meet was the salaries
of tlie professional Community Health Staff.
In a case where people would not have been in a
position to give money, paddy was collected once
a year for the programme.
.'.■.11.-
:
11
:
b.From the Government: Help is available from
different government schemes:
- medicine (vaccine - iron - folic acid. - vit.A)
- benefit of special schemes under the block such
ns seed, sewing machines, trees, chickens
- service of qualified personnel; for animal hus
bandry, agriculture
- special training organised by the block for
village people
- in case you are working in a small dispensary;
reforal of your patients to the PHC.
Money is available for special programmes such as
well digging, pond deepening etc.
Such programmes
are under the supervision of the BDO and he is the
person to approach for it.
Money is available for special health programmes
such as TB Control, Leprosy Control Programme.
In
such cases we must follow all the rules of the
government for such programmes and the programme we
will undertake will have to cover a specified, fairly
big area.
c.
Companies; Business companies can be contacted for
kind and money.
This is mainly applicable in case
of emergency.
d.
Clubs; Rotary - Lions - Wheels etc. give mainly funds
for short term programmes and charitable activities.
Most of them are much interested in immunization
programmes and eye camps.
e.
Red Cross; In case of emergency only.
Generally the
Rod Cross run their own programmes but in some cases
voluntary programmes got substantial helps from them.
This was the case during the drought of 1966-67 in
Bihar.
The Red Cross supplied important food and
medicine stock to a voluntary agency working in
Palamau.
«.
f.
Social Welfare Board; Is a state welfare association.
It helps with grants in womens’ development progra
mmes and childrens programmes.
g.
Specialised Welfare Boards;
The specialised Welfare
Boards are governmental, such as Tribal Welfare Board.
They help in programmes for the marginal groups of the
society.
h.
Donor Agencies in India; Caritas-India, Indo German
Social Service Society, Catholic Relief Service,
Care, CASA etc.
i.
Donor Agencies outside India:
As far as possible the cost of a Community Health
Programme should be met by local resources: community
government - local clubs and companies.
12
12
In case all the cost of the programme cannot be
met from local resources appeal can be sent to
a donor agency either in India or outside India.
But we have to remember that no donor agency
will assume the financial responsibility of a
Community Health Programme for a long time.
At
the most a donor agency will be ready to help
meet the recurring cost of a programme for 3 to
4 years.
After that time it will still be your
problem how to meet the recurring cost of the
programme.
This is why we strongly advise you
to try, from the beginning, to have the cost of
the programme met by the local resources and to
plan your programme according to the availability
of the local resources.
In case, the community
cannot bear the full cost of the programme you
could of course ask a donor agency for a grant
to begin with.
But then you should seriously
study how the programme is to become self-suffi
cient.
Perhaps it could be possible to have an
income generating programme supporting pare of
the expenses of the community health programme.
V.
CONCLUSION
In this paper we have tried to help you in becoming
aware of what should be done before starting a Community
Health Programme.
We have seen the necessity for you
to have a good knowledge of the area where you intend
to have your programme and where most of the informa
tion you require can be obtained from.
We have seen that it is important to consider care
fully the professional staff necessary for such a
programme and the cost to be foreseen.
You should thus, at this stage, be able to choose a
target area and plan for a small programme to be taken
up by your centre.
But before you start implementing the programme you
will have to go a step further and select a few
villages, situated in the target area, where you
would start the programme.
In another paper we will
study with you how to select villages for starting a
Community Health Programme.
Prepared by:
Community Health Team
Voluntary Health Association’of India
0-14, Community Centre,S D A,
New Delhi-110 016 •
Catholic Hospital Association of India
C. B. C. I. Centre, Goldakkhana, New Delhi- 110001
Tel. 310694, 322064
PLANNING A PROGRAMME
All health teams basically want to improve the health of
the people.
In doing this the team already has some guide
lines.
For example, we all know that there are national
priorities such as Mother and Child Health, Control of TB
and Leprosy, raising the level of literacy, reafforestation
etc.
In the villages we have chosen, there will be other
problems also such as lack of sanitation, water, migration
etc.
We cannot deal with all the health related problems
of a village at the same time.
We will have to set priori
ties.
This means that we will have to decide which pro
blems we want to deal with first.
We should also be clear
about how we are going to deal with these problems.
It is
therefore important that we plan our activities.
PLANNING HELPS US IN;
- identifying the problems clearly
- deciding what we want to achieve through our
action
- working systematically
- making better use of our limited resources
-studying the results of our action
STEPS IN PLANNING:
STEP 1.Identifying the problem:
We must first find out the
in our villages.
This can be done;
- through observation (keeping our eyes and ears open
- through discussions with village people, formal and
informal leaders
- by studying the out patient records
- by doing a survey
STEP 2. Set priorities:
To do this we make a list of all
the problems we have found in Step I.
These may
be medical ones:
Eg.Malnutrition, Diarrhoea, Malaria, Scabies,
Tetanus etc., or non-medical ones: eg.illiteracy,
migration, deforestation etc.
A health team cannot deal with all these problems
at the same time.
So we need to set priorities by
asking ourselves for each of the problems:
- What is the extent of the problem(How many people
are affected by it)
- how serious is the problem
- how concerned is the community is solving the problem
- how easily can the problem be solved
We give points (0-4)
*
for each of these answers and multiply the points for a problem to get the result.
* Note;
0
1
2
3
4
means
means
means
means
means
not at all
little
somewhat
quite high
very high
2/
2
Our priority problem will be the one which gets the high
est score.
FOR EXAMPLE, let us take four problems and work out the
priority.
Diarrhoea
- is common (about 60% of our OPD cases are
diarrhoea)
- is serious because it causes death
- community is concerned because so many children
die of diarrhoea
- we can do something to solve the problem
Scabies
- is very common (every second person in the
village has it)
- It is not serious (people do not die of it)
- community is not concerned about it as the
people can continue their day to day work
- we cannot do much about it unless the whole
community is interested in removing this
disease from the village
Illiteracy - is common (only 13% of the population is
literate)
- is serious because it leads to a lot of ex
ploitation
- community is somewhat concerned
- we can do something to solve the problem
Deforestation
- is common
- is serious because it leads to decreased
rainfall and poor soil
- community is concerned about it
- it is difficult to take immediate action
Problem
.........
- -i i■ ■
Diarrhoea
Hq,w
Community
Can. do■«'
■How'iwide' ■
■ — i ■■ - ■ ..■■■■»<■ .......
.
serious
concern something
about it
Score
■■
n
Scabies
3
4
illiteracy
81
X
X
3
1
X
3
1
3
X
2
X
3
54
4
X
3
X
1
48
X
X
3
1
3
X
Deforestation 4
X
X
=
4
From the above it is clear that diarrhoea, though less common
than scabies and deforestation, needs immediate action.
So
diarrhoea becomes our priority problem.
Illiteracy is the
second priority.
We should remember that the scores for each problem can be
different for each village.
Also we must select our priority
problems after doing the four factor analysis for all the pro
blems we listed in Step I.
STEP.3 Find out how the problem is caused; After we decide on
the problems that we want to deal with first, we find out re
asons and causes of the problem.
This is called community
diagnosis.
For example, if we take our priority problem of
diarrhoea our community diagnosis may look like this.
(see next page).
COMMON I T Y
DTAG- N 0 S I S
of Diarrhoea in Children
Agriculture depends
on rain, rain fails
or there is too much
Lack of interest
No knowledge about
what is available
from outside I
No co-operation Lack of education
11 (a)
Soil gets
washed away
J,
THERE ARE
•BEING CUT
f.
Poor crops.
People poor
"decrease
Undergrou
water
decreases
Land not
fertile ?—Same kind of crops
X
Govt, not
giving enough
importance
to villages
People not
No help
from out- interested
\ side the
village
NO
WELL
Not enough food
Continous''' Lack of fertilizers
fanning
'h
LACK OF CLEAN
DRINKING WATER
UNDERNUTRITION
No money
to buy
People are
poor and
cannot dig
Tbo many
people using
the same well
Mother is.
^Mother is
lover worked careless
--------------------------------FOOD NOT COOKED /
PROPERLY
She ha s two jobs
- house work plus
- other work
! POVERTY
I
Well is not clean
DIARRHOEA'
IN
CHILDREN ,
\ FLIES
Bad Sanitation
Lack of knowledge
about the spread
of disease
Values in
Society
i
B
I
REMEMBER: This Community Diagnosis is not complete.
There can be many more reasons which-lead
to diarrhoea in children.
Find out the
actual reasons from the people in each of
your villages.
A complete diagnosis leads
to a complete treatment.
Not many
animals
t
4
i
The above chart is only an example.
Wo must talk to tho
people in the village and find what are the reasons for
the problem in that village.
ST3F 4.
Decide on a Plan of Action
In Step III, we will have found many reasons for our
priority problem.
It is now our task to see, with
the community, what can be done about the problem.
For example, from the community diagnosis of diarrhoea
we can see what are the main causes of diarrhoea and
whether we can do something about them, like this.
Main reasons for
Diarrhoea
Can do something
about
I.Lack of clean
drinking water
- educating people
to keep well clean
- help people to get
help from Govt.for
digging a well
2.Food not cokked - educating mothers
properly
about feeding practices
- organizing women
to share respon
sibility of all
under fives
- motivating elder
children to help
in proper feeding
of under fives.
3.Flies
- educating people
about how dis east)
spreads
4.Malnutrition
Difficult
to {Ip,
3o»ne
Difficult to
change Values
in society
Difficult to
deal with bad
sanitation
immediately
Difficult to
deal with agricultual proble
ms right now.
---------------------------------------Other ideas
-training VHW's to
provide medical
facility in vi
llages
-educating mothers
and VHW's on danger
signs of diarrhoea,
preparation of rehy
dration drink, need
for early actin etfci
In the above example, we notice that it is ^ftsier to do
something immediately to reduce deaths caus<jd by diarrhoea.
However it is more difficult to decrease th
*
number of
cases of diarrhoea.
For this we would need& to do something
about undernutrition and sanitation also.
^t wi,ll. take a
long time to think of ways of solving the pf^pblems of under
nutrition and sanitation.
i
5
>
STBP 5. Making plan:
We have decided with the community
what we are going to do about the priority problem
in Step 4, now wo must discuss who will do what,
how and when.
If money or equipment is required,
how will we get it? For example, we consider
what is needed for two of the activities wo deci
ded in Step 4, column 2.
Activity as decided What needs to
in col.2 of Step 4
be done
do by require
.
when money/
-------------- equip
*
ment
------------
.
i.Sducating people
to keep well clean -Find out the
reasons why
well is unclean
-Talk with
people indi
vidually and
in groups to
deal with
reasons
-Find out
possibility of
building platform around
the well
W
-Contact PHC
staff to get
bleaching
powder
2.Help people to get
-Find out
help from Govt, for where the well
digging a well.
is to be dug.
-Find out how
many people
will benefit
from this well.
-Contact Gram
Sevak, BDO
-Get the village
representatives
to write a
petition to
the BDO.
41
-Fix up meetings
with BDO and
representatives
X JC X Z X X X
Prepared byl
Community Health Team
Voluntary Health Association of India
C-14, Community Centre, S D A,
New Delhi-110 016
ANALYSIS OF THE PRESENT HEALTH CARE DELIVERY SYSTEM
IN INDIA
To start with, let us examine the rationale and. relevance
of an analysis of the existing health care delivery system.
Let us have a look at the following statements based on
authentic statistical information:
India has the highest mortality rate - 133/1000, among all
the Asian countries.
In India diarrhoea alone kills 3 children every minute or
1.5 million each year. Every minute an Indian child is ex
posed to it.
Infant mortality rate of India is 125 (1978).
There are about 60 million children in India who are mal
nourished.
There are an estimated 3.2 million leprosy patients in India.
Tuberculosis accounts for 3% of the 1 crore annual death
in India.
Severe degree of anaemia has been detected in 12% of pre
school children.
90 million children are supposed to be in the polio danger
zone and 13 million are added to this figure every year.
Of these, 80% victims are below 3 years and 15% below 5 years.
There-are 2.5 lakh totally blind children.
There are about
1.8 lakh partially blind.
There are another 2.5 lakh who are
deaf. Of the 9 million blind persons in the country, 5
million could be cured by proper surgical interference.
All these are certain important indicators of the health
status of India's 70 crore population. India adores tenth
place among the industrialized nations of the world.- Pla
nners and leaders narrate success stories of various deve
lopment programmes and the progress achieved in various
,sectors. Hut the lot of the common man and the labourer
continues to be the same and becomes worse even.
The illhealth and the high death rate are but the manifestations
of the miseries that majority of the population undergo in
this country. Here it rightly follows that development and
health are integrally related.
At the very outset of this
discussion let us try to situate the sick man in the context
of this socio-economic situation prevailing in India.
Development means the satisfaction of the basic needs of the
poor who constitutes the world's majority; at the same time,
development also means ensuring the humanization of man by
the satisfaction of his needs for expression, creativity,
and the capability for deciding his own destiny. Here
again the stress is on the poor man - the satisfaction of
his needs and ensuring the removal of all dehumanizing
forces and enabling him to be master of his own destiny.
Health forms one of the basic needs of man; and more than
..2/-
-2-
that, sound health is primary for human existence.
The first
part of this paper presented few instances showing the grave
denial of this right to existence.
The 'Alma-Ata' declara
tion of the Internationa?. Conference on Primary Health Care
(.organised by WHO. Sept. 12,1978) also reaffirms the import-j
ance of health and goes even further to state that health is'
essentially a state of complete physical, mental and social !
well-being and not merely the absence of disease or infir
mity. If viewed against this background, provision ofhealth
for all" which is a. declared objective of WHO and that of the
Government of India, demands of comprehensive state of
national welfare based on equity of distribution in which
none denies the right of the other for health. Hence health
demands the good harmony of social, economic, political,
cultural, and religious forces conducive to the promotion of
healthy existence of man,
In the existing society, the health care system is part of
the wider social, political and economic system.
The social,
political or economic capability is not equally distributed.
According to the 1981 census, 48.44% of the Indian population
are below the poverty line. Unofficial calculations, which
often picture the real state of affairs, suggest the figure
to be 75%.
This figure goes on increasing.
According to
1981 price scale, a person who does not have Rs. ?/- a day is
considered to be under poverty line.
This phenomena is due to
the anomalies of the distribution system which prevents the
poor from meeting his needs. In the wider economic and poli
tical relations, the health system alone cannot be thought
of as being isolated. Unequal distribution of health care
facilities denies the right to sound health to the majority
of our population.
Socia?. and economic inequalities and
powerlessness nrohib.it the people from the knowledge and the
capacity
afford the health care of their family-the pre
gnant, the children, the adult and the aged. Hence, inequ
alities exist at two levels - (a) in the distribution of the
health care service (b) in the capacity of the people to
afford to maintain good health. Precisely, these two areas
constitute the central theme of this paper. We shall follow
a sequence and order based on the points given below:
a. The present health care delivery system in India
and its distribution in the rural and urban centres.
b. Availability of these facilities to different econo
mic classes and medication practices.
c. Problems of medical personnel in rural areas.
d. Manufacture and distribution of drugs.
Prior to the discussion on the above let us have a brief
look at our national health policy.
Our national Health Policy
The constitution of India aims at the elimination of poverty,
ignorance and ill-health and directs the State to regard the
raising Idvel of nutrition and the standard of living of its
people and the improvement of public health as among its
primary duties, securing the health and strength of workers,
men and women, specially ensuring that children are given
..3/
-3opportunities and facilities to development in a healthy
manner. Hence with a view to providing health for all by
2000 AD., the Government of India has revised its health
policy in relation to the economically under-previleged
sections of the Indian population, and especially those in
the rural areas who constitute 80$ of the total population.
The revised statement on the National Health Policy covers
areas as population stabilization, reorienting medical and
health education in relation to the health needs of the
rural and urban poor, need for providing primary health care.
with special emphasis on the preventive, promotive and the
rehabilitative aspects, reorientation of the existing health
personnel, promotion of indigenous and other systems of
medicine, etc.
The policy statement considers the problems
of nutrition, food adultration, quality of drugs, water
supply and sanitation, environmental protection, immuniza
tion programme, Mother and Child health service, school
health programme, occupational health service, medical indu
stry and medical research as areas deserving urgent attention.
All these are geared to providing all the citizens of India
sound health, especially those in the rural areas who forms
India's majority of population.
Yet alarming statistical figures glare at us. We have to
admit that the existing health care delivery system does not
cater to the needs of the majority of the people.
The poor
and the under-previleged, especially those in the rural areas,
form the majority of the victims of ill-health. We have to
admit that based on this status-quo we have to implement one
by one the meaningfully laid down policies of our National
Health Policy. Now let us pass on to discussions on the
various points mentioned already.
(a) Health Care Delivery System in India:
i. Administrative set up at the Centre,
State and District levels
The official organs of health at the national level consist
of (1) The Ministy of Healthand Family Welfare (2) The
Directorate General of Health Services (3) The Central
Council of Health.
The functions in the union list for the ministry of health and
family welfare are international health relations and admini
stration of port quarantine, administration of Central in
stitutes, promotion of research and research bodies, regu
lation and development of medical,pharmaceutical, dental and
nursing professions, establishment and maintenance of drugs
standards, immunisation & emigration, regulation of labour
and working of mines and oil fields, co-ordination in the
States and other ministries for promotion of health. For
functions in the concurrent list both the Centralend State
ministries are jointly responsible.
They are prevention of
extension of communicable diseases, prevention of adulter
ation of food stuffs, control of drugs a.nd poisons, vital
statistics, labour welfare, etc. Both Centre and State
Governments have simultaneous powers of legislation.
4/-
-4-
The Directorate General of health services is the principal
advisor .0 the union Government in both medical and public
health matters.
The functions are surveys, planning, co
ordination, programming and appraisa.l of all health matters
in the y
*,
conntTn brihf, the specific functions are inter-<.clth relations and quarantine, Control of drugs
standards, management of medical stores depots, post
graduate training, medical education, medical research,
Central Gove, .c-alth Scheme, "national, health programmes,
Central Health Education Bureau, health intelligence, and
maintenance of national Medical Library.
Since many health subjects fall in concurrent list, continuous
consultation, mutual understanding and cooperation are nece
ssary between Centre and States.
The Central Council- of
Health, constituted of the State ministries of health with
the union minister as the chairman, looks into these. Briefly,
the functions ere - to consider and recommend broad lines
of policy in matters related with health, to make proposals
for legislation, to recommend to Central Government for dis
tribution of grants-in-aid to States and to review the uti
lization of that, to establish organisations for promoting
cooperation between State and Central health ministries.
11State Level
The health subjects generally fall in three headings federal, concurrent and state list.
The state has complete
autonomy for the functions prescribed in the State list.
Generally, this includes the provision of medical care,
preventiv health services and pilgrimages within the State.
And, the State is the ultimate authority responsible for all
the healtn services perating within its jurisdiction.
Tn al? '1
-~oes tne management of health sector comprises
of the Stare Ministry of health and the directorate of health.
The State Ministry of health is hea.ded by a minister of
health and family welfare.
some States the Health Minister
is also incharge of other portfolios.•
The Director of Health Services (known in some States as
Director of health and medical services) is the chief tech
nical advisor to the Government on all matters relating to
medicine and public health. He is also responsible for the
organisation and direction of all health activities.
With the advent of family planning programme, in some States,
the designation has been charged to Director of health and
family -planning. In some States a separate Director of
medical education is also appointed tq be in charge of medical
education.
The Director of health and family planning is
assisted by a suitable number of assistant director, whose
appointment may be either on regional(basis or functional
(specialists in different branches of public health) basis.
IiI. District Level
There are wide differences in the pattern of district health
organisation.
The following types are seen (a) One district
chief, one District Medical officer of health, assisted by
two or mere deputies.
(b) Two district chiefs - in this set
..5/-
-5up the civil sugeon/District Medical Officer looks after the
district hospital, and sometimes all medical facilities in
the district, and the District health Officer is incharge of
public health.
People's Participation
The rural local self Government of India, 'Panchayati Raj 1
institutions are meant to ensure people's participation for
the various welfare programmes including health
*
Panchayati
Raj institutions are elected bodies. It functions at three
levels:
1. Panchayat - at the village level
2. Panchayat Samithi - at the block level
3. Zilla Parishad - at the district level.
The appointed persons of the Government infrastructure at
the district and the block level are the implementing agen
cies.
The local self Government functions as a supervisory
and coordinating body.
ii.
Health Care System - distribution
The health care system of India may be defined as the" industry
which provides health services (health activities ) so as to
meet the health needs and demands of individuals and the
community." It operates in the context of the socio-economic
and political system of the country. It is represented by
the 5 major sectors or agencies which differ from each other
by the health technology applied and by the source of funds
for operation.
These are:
I.
Public agencies
,
1. Prima.ry Health Centres
2. Hospitals - Rural hospitals
- District hospitals
- Specialist hospitals
- Teaching hospitals
3. Health Insurance Schemes
- Employees State Insurance
- Central Govt. Health Scheme.
4. Other agencies
- Defence Services
- Railways.
II.
Private agencies
1. Private hospitals, Polyclinics, Nursing homes and
dispensaries.
2. General practitioners and clinics.
III. Indigeous Systems of Medicine
- Ayurveda and Sidha
- Unani & Tibbi
- Homeopathy
- Unregistered practiticnors.
..6/
-6IV. Volu~tary Health Agencies.
V. Vertical Health Programmes.
I. Primary Health Contres;
The primary health centre is de
find as an "institution for providing comprehensive (i.c.
preventive, promotive and curative) health care services to
the people living in a defined geographic area. It seeks
to achieve its purpose by grouping under one roof or coor
dinates in some other manner all the health work of that area".
It is the minimum infrastructure for the delivery of health
care services to the rural people.
The scheme started in
1952.
The Centre is usuo.lly located at the headquarters
of the Block, and serves the population of the Block coming
upto 80,000 to 1,20,000 spread over in about- 100 villages.
To bring the services closer to the people 'sub-centres'
are established at the rate of one sub-centre for every
10,000 population.
At present there are 5372 PHC's and
37,775 sub-centres (1979).
The PHC provides accommodation
for an outdoor dispensary, a consultation room, accommo
dation for MCH/FP services, minor surgery? a small laboratory
and a ward of at least 6 beds, out of which 4 are maternity
bods.
Since the PHC is not equipped to deal with compli
cated medical, surgical and obstetric and gynaecologic.nl
cases, it is linked up with the subdivisional and district
hospital in the region where X-ray, laboratory and specia
list services are available.
Function of PRC:-
1. Medical Caro
2. MCH and Family Planning
3. School health
4. Improvement of environmental sanitation with priority
for providing safe drinking water and disposal of human
wastes.
5. Control and Surveillance of Communicable diseases.
6. Collection and reporting of vital statistics.
7. Hea.lth Education
8. National Health Programmes - as relevant
9. Referral Services.
Health Team
PHC:
'
Medical Officers - 2
Computer
1
Compounder
Sanitory Inspcctor-1
Auxiliary Nurse
midwife
Driver
• t
1
Health Inspectors
Ancillary staff
2
Extention
Educator
- 1
2
1
(F.P)
..7/
|
-7Sub Centre:
Health Worker Female (HWF)
- 1
Health Worker Male
- 1
(HWM)
Health Assistant (Male)
Health Assistant (Female)
- 1 (for 4 HWM)
- 1 (for 4 HWF)
The PHC thus provides a. team work to the health problems
of the community.
The sub-centres are established at the rate of one per 10000
popula.tion. Health Planners visua.lise one sub-centre for a
population of 5?000 or even less, in the near future, when
resources permit.
A sub-centre with a population of 10,000 would yield?
i. Target population for family planning
ii. Deliveries
iii. Infants
iv. Pre-School children
v.
School children
2.
Hospitals:
- 1,500
400
400
- 1,500
- 2,500
Apart from primary health centres, the present organisation
of medical care by the Govt, sector consists of Rural Hospital,
International hospitals (2 to 3 lakhs population), District
hospitals (1 to 2 million), specialist hospitals (eye, TE,
leprosy, cancer etc. ) and Teaching Institutions.
In addition mobile hospitals are also under trial.
Difference between Hospitals and PHC's:
Hospitals
PHC1s
- Curative
- Curative, preventive, pro
motive and all integrated
- No particular
catchment area
- Catchment area - 80,000 to
1,20,000 people of about
100 villages
- Only curative staff
3.
Health Insurance
Limited only to Govt, employees, eg., ESI. , Central
Health Scheme.
4.
Govt.
Other agencies: Medical services to employees of Rail
ways, Defence personnel etc.
II. Private agencies
There are private hospitals, clinics, dispensaries and private
medical (allopathic) practitioners.
..8/-
-8III. Indigenous system of medicine:
The practitioners of
indigenous system of medicine - Ayurveda, Sidha, Homo
eopathy, etc., provide the bulk of medical care to the rural
people.
Voluntary health agencies:
They occupy an important
place in Community Health Programmes.
They supplement
and guide the work of officia-1 agencies.
Eg. - Indian Red
Cross Society, T.B, Association of India, Family Planning
Association of India etc,
IV.
Health Programme in India: Since India became free,
several "measures have been undertaken by the union gover
nment to improve the health of the people. Prominent among
these are a number of vertical health programmes known as
National Health Programmes which have been launched by the
Central Govt, for the control/eradication of communicable
diseases, improvement of environmental sanitation, nutrition
and rural health. Eg. - National Malaria Eradication Pro
gramme, National T.B. Control Programme, VD Control Programme,
National F.P. Programme etc.
V.
The following table gives the number of hospitals and PHC's
in India.
1. Number of hospitals and dispensaries
2. Number of PECs
- 17607 (1977)
5372 (1979)
3. Number of Subcentres
4. Hospital Beds
-■ 37775 (1979)
-449212 (1979)
This table represents the tota.ls at the all India level.
Those do not, however, represent the rural and urban split
up figures.
In spite of all the schemes briefed in the previous para
graphs, eight out of ten Indians have little or no access to
modern medicine.
The number of doctors in 1980 was2,53,631•
A WHO study mentions that India has sufficinet number of
doctors. But the problem is the lack o fa distribution systerp
which equally gives importance to rural and urban areas.
Thus the existing health personnel can hardly meet the needs
of the people.
The ratio of the hospital bed and population,
is 0.49 per 1000 population.
The doctor population ratio
is 1:4400.
When taking split up figures for the rural and
urban areas, rural area has the ratio 1:20,700 and the urban
area has 1:1 ,300..- Thus the rural folk suffers seriously
from lack of enough number of doctors.
80% of the Indian
population live in villages. But 80% of our health care
facilities and personnel are in the urban entres catering to
the needs of a minority of the Indian population (20% of
population).
This fact explains the ill-health of the
majority of Indian population.
The very same fact explains
the high incidence of infant mortality, spread of communi
cable diseases and high death rate.
The Indian child succ
umbs to death due to some diseaseswhich are generally
preventive if sufficiently cared for at the proper time.
9/
_o_
Here again, the reason could bo attributed to the genera,!
inaccessibility of the India.n population to the hoa.lth care
facilities in spite of continued establishment of hospitals
nd private sector.
both in the government e.
(b) Availability of health care facilities to the Poor;
Wo have already seen the disparity in the distribution of
health ca.ro facilities and the doctor population ratio for
the rural and urban areas.
As mentioned already, this
disparity its.If is one of the main reasons as to why majo
rity of our population - poorer sections of the society
dwelling mostly in rural areas - are denied the right to
adequate health care.
Government and private health care services are available in
India.
As alroa.dy mentioned the Government has started some
rural health programmes. But certain impediments stand in
the way as: a. Lack of participation of the people - which develops
a certain apathy and disinterest towards the Govern
mental programme, thus affecting seriously the desired
objective of being of help to the very same people.
Co-operation of the people and the health personnel
is vital.
There
b.
is a certain attraction to work in the urban
areas and the health personnel lack the motivation to
work in the rural areas,
This is a very clear phenomena
found everywhere.
This problem is dealt with under
a separate heading. Hence when the medical officer
or health worker is placed in a rural area he will not
commit himself fully but will try for a transfer to the
more convenient urban centre.
c. In'the annual budget allocation,' sufficient funds are
not available to the rural centre for the purchase of
medicines and the maintenance of other facilities of
the health centre. Lack of follow up thus gravely
affects the health programmes. 75% of the budget allo
cations are for maintaining staff, 12% for transport,
12% for drugs and 1% for innovative experiments. When
we take rural outlays it is seen that they are remar
kably lesser when compared with the corresponding
urban allocations.
The Constitution of India has considered health care as a
basic need of the citizens and has assured that it should
reach to the people. But the people cannot expect good
service from the Government health centres.
Poor maintenance
and lack of facilities are two main reasons. Health care
centres as PHC's and sub-centres present a very poor show.
District hospitals also do not come upto to the mark.
Medical colleges and sophisticated Governmental institutions
are generally equipped with all the modern medical access
ories with specialists for each branch. Medication at
these Centres a.re, however, controlled by money power.
Corruption has eroded public life and health care insti
tutions are also no exception to this phenomenon. Private
. .10/
-11-
.
to approach the commercialized modern medicine. Distance
to the medical centres and lack of enoughtcompetent medical
personnel in backward areas make the situation still worse.
Problems connected with the dearth of competent personnel
are being: dealt with under the next heading.
c»
Problems of medical personnel in rural areas;
The training and motivation of the health personnel is very
important as regards rural health work-.- Speaking of training
just like any other branch of education, medical education
also should bo sensitive to the social environment of the
community which it socks to serve, and constantly adapt it
self to the changing requirements.
The motivational part
of the person is greatly influenced by the content and value
orientations of the training. In the paragraphs that follow
the descriptions are mainly about doctors, since, inihe
present sot up, even in the rural areas, the graduate doctor
remains the chief person as regards health care.
The present medical educational system is strictly hospital
based and westernized and hence tho doctors do not inher it
an aptitu.de or attitude to work in tho circumstances and
atmosphere of rural India.
The doctors also lack an under
standing of the social, cultural and religious concepts of
health and disease in rural India as well as the attitudes
and practices concerned with food, child-birth, child care
and general health care.
Similarly there have been very
many traditional systems of medical -care.
Tho modern system
of medicine takes much time to gain acceptance in Indian
villages.
It is c. basic question cf cultural difference.
Also it should be noted that certain traditional ways of
health care are advisable for certain diseases.
Thus it
counter acts the many adverse effects of modern medicine,
The modern medical education doos not consider these cultural
factors in health can?e.
And also, generally a modern doctor
has but contempt for the "uncivilized, uneducated" villager
in tho place of respect as an individual.
Apart from these, a doctor working in rural area, is exposed
to the following problems
- inadequate living conditions and inability to maintain
an urban standard of living which most medical students
become used to.
- Poor or relatively poor financial remuneration and/or
allowances/compensation.
- Problems of adjustment when accompanied by wife and
young children, especially the education of the latter.
- Objection of families to rural work especially because
of a low.er social status in the profession.
* This part of the paper was prepared after closely
referring ’Trends in under-graduate medical education
in India', prepared by Dr. Ravi Narayan.
12/
*
-12- Social isolation. 10001x80 of an inability to fit in with
the simple rural way of life, (more pronounced when the
doctor comes from a predominantly urban background)
L~d- ?i x-o.pport and contact between urban and rural commu
nities to an extent, which makes a doctor feel complete
ly 'out cf place1 or 'cut off' in the rural areas.
- Intellectual isolation and inadequate opportunity to
maintain professional compentence or to gain post gra
duate experience under supervision.
- Problems of political interference in work and often
poor relations with local government officials, leading
to frequent transfers.
- Problem of interpersonal relationships with other members
of the team, especially when many are older to him and
have had longer contact with the local people.
- Presence
and, often, professional competition with
practitioners of other indigenous systems of medicine.
- Another major obstacle to attracting doctors to rural
areas is the attitude of the medical profession to rura.1
work, especially in the light of the present day 'ideal'
of specialist practice in the largo cities.
This reflects
a general trend towards an intensely materialistic orien
tation of the medical profession.
Consequently, thb
preparation and motivation for rural work in the medical
college curriculam has always been inadequate.
Now, wi th this we shall pass on to another important area
of concern 'DRUGS'.
(d) Manufacture and Distribution of Drugs:
xne true tore of drug industry embodies all the essential
features of the industrial economy of India.
Thus, like in
the case of any other industry, profit orientation, monopo
lization, promotion of multi-national corporations, compli
mentary role of public sector etc., are seen here also.
Drug costs represent 40-60% of the total health care expen
diture in developing countries like India. In developed
countries the corresponding figure is only 10-20%.
Let us have an enquiry into the reasons for such an unde:.sirable state. Let us now examine some of the evil effects
the industrial end commercial nature of drug manufacturing
brings in:
Production for profit:- Just like any other industry here
too production is based on demand and hence profit. Since
majority of tho Indian people are below the poverty line they
find it hard to purchase medicine.
The per capita consum
ption of medicine in India, is only Rs. 5/-.
According to
1973 calculation, 80% of the drugs produced in India are
bought by 20%.
The rest of tho population shares only the
remaining 20%.
Mono-polios: - According to 1973 calculation, out of Rs. 370
crores worth of drugs produced by 2300 firms in India.
Es. 296 cror^s/of drugs were produced by 110 firms (4% of Zwor’th
the total). Of ’Chose 110, '28 are foreign owned or
13/-
collaborated firms and they account for 40% of the total
production.
Always production is meant for profit.
Artifi
cial scarcity is created by few monopolies coming together.
This is to increase the price. If the full capacity of the
factories arc utilized the common man would have got medi
cines at a comparatively low price.
The monopolies decide
the price vrhich doos not at all correspond to the rea.l cost
of production.
eg: Bulk selling price of chloramphenicol is 3 times
its production cost.
Tetracycline it is 2.7 times.
Retail price will be still higher
Chlord^henicol - Bulk selling price
Retail price
- f$s. 400/- kg
- Es» 3,050/- kg
For Vit. B^2 the retail price is 20 times the
bulk selling price.
For Vit. C
the retail price is 5.times the
bulk selling price.
Corresponding figures for Folic acid & Tetracycline
are 9.2 and 4.5 times respectively.
Multinational corporations;for 40% of total production.
As stated earlier, they account
In pricing they are still worse.
Eg. while we import Librium at Rs. 312/-kg it is\
produced by. a Swiss firn in India for Rs. 5555/v kg.
Another foreign firm was charging Rs. 60,000/-kg for Dexame
thasone vrhich vras later reduced to Rs. 16,000/-kg.
Another usual practice is that the subsidiary of the foreign
firm in India, buys the penultimate product from its parent
company at high rates, makes the final product, sta.mps it
as made in India and sells i't at fantastically high rates.
The aim of production and research either in India or abroad
remains that of maximizing profits.
Public Sector:- The public sector do not curb the fraudulent
practices of the private firms but they compliment it.
Ono
example could be that Hindustan Antibiotics Ltd. sell Stre
ptomycin at Rs. 345/- kg in retail, where as the same medicine
is sold to private sector at Rs. l95/-kg which in turn takes
the profit.
Another public sector firm sell 54% of its bulk production
to private firms. Just like other fields of industry hero
too public sector sells its semi-finished products to the
private firms which take huge profits on the finished pro
ducts.
Thus the people's taxes arc used to make profits to
few giants. All these are some of the examples to show the
fraudulent practices in drug industry.
The data regarding
the pricing had been of 1973 - 1974 period.
After that the
14/
-14-
situation nigLit have become worse or in few exceptional cases
improved little. It has yet to be found out.
The data pre
sented above are a few indicators as to how the drug industry
exploits the common man. With the development of pharmacology
and chemical engineering it is possible to distribute com
paratively cheap drugs on a la.rge scale to all needy. But
the social organization of our economy is such that the aim
of production becomes profit oriented.
Advortisements;
The advertisements cheat the people misera
bly. Evon medical practitioners arc deceived by attractive
advertisements of different medicines.
A case of deception
of the common man by advertisements could be "breast-feeding".
The people arc attracted by be.by-foods a.nd there had boon
instances to show that while a poor man had oven no sufficient
income to feed his family ho resorted to ba.by-foods thinking
of breast feeding as socondory.
Use of Drugs:
The promotional practices of drug companies,
aimed at maximizing profits, have been directly counter to the
health needs of the poorest.
The brunt of wasteful spending
falls on the poorest, as the rural dispensaries run short of
vital life saving drugs.
Apart from promotion of unnecess
arily expensive, but neccssa.ry drugs, doctors are also encour
aged into wasteful over proscribing
non-essential tranqu
ilizers, symptom
*
allaying drugs and tonics. Similarly
drugs freely promoted in the absence of distribution controls
can a.lso cause serious dangers.
The existing system of quality control of drugs is not
satisfactory.
600 drug inspectors in India, have to chock
30,000 drug formulations.. The beurocratic defects worsen
the situation still-decision making, implementing decisions,
etc.
The marketing of most brand - named drugs especially
by the multinationals in the third world works a.gainst the
health of the poor.' Also, drugs banned in the west or used
under severe restrictions always continue to be liberally
used in India eg. anabolic steroids, ana.lgin etc.
Bearing in mind the very limited, effectiveness of drugs and
curative medicine in tackling the health problems - mal
nutrition, inf ections and parasitic diseases - public funds
would be far better spend on preventive health measures and
the basic primary health care infrastructure.
For this,
WHO estimates that 200 genuine drugs would bo more than
sufficient to moot the health needs.
Orientation towards "appropriate use of drugs" has to yet
be developed. Our proscription practices have to be modi
fied according to the needs of the people.
Our choice of
drugs for stocking in the pharmacy should be according to
this. Most important of all, the emphasis has to bo oh
people taking responsibility for their health and avoiding
those drugs as far as possible and rrieg those "non-drug
therapies" that have boon recognized to have good therapeutic
effect. Education and awareness as to how to a.void disease
and then how to handle it appropriately at the lowest possi
ble cost is the crux of our approach in low cost appropriate
health care.
..15/-
-15-
Conclusion:- A brief enquiry has been made into the general
edistribution of health care facilities and health personnel
in India. Availability of service to the rural (poor) popu
lation has been the c’.ore of the discussion, since the
problems of villages represent the problens of the entire
country. Health ca.re in India is being situated in the
context of the existing socio-politico-econonic realities.
Probions and issues have been raised in this context.
It
is hoped, these would serve as certain indicators in the
sea.rch for the right type of hea,lth services for this under
developed country.
.tain references:
Patil Ashwin J- In Search of Diagnosis.
Indian Council of Social
Science Research and Indian
Council of Medical Research
Health for all - An
alternative strategy
The National Health Policy
of India.
Volun+":jyHealth Association
of India.
Information (Journal)
PREPARED BY: THE CATHOLIC HOSPITAL ASSOCIATION OP INDIA
C.B.C.I. CENTRE
ASHOK PLACE, GOLDAKKHANA
NEV? DELHI 110 001.
Catholic Hospital Association of India
C. B. C. I. Centre, Goldakkhana, New Delhi - 110001
Tel. 310694, 322064
Sr... J0SE.„ CASE. STUDY
Sr. Jose has just completed a 10 months post graduation
training in Public Health Nursing and is told by her superior
to join the convent of Rasi. Rasi is a village of about 2,000
people situated 20 km. avay from the district town, where the
Catholic Mission is well established. The Catholic Mission has
a higher elementary school, co-cducational, with 500 children
out of which 300 are boarders with the Mission. These boarders
come from villages situated as far as 50 km, away from Rasi.
There is also in the Mission, a Grihini Training School which
can up to 50 boarder girls and a health centre under the manage
ment of one sister RNRM, sister Mary, helped by one lay AMvi and
two locally trained girls.
Sr. Mary has been visiting the nearby villages whenever
she could find time. She generally goes to the villages with
one of the sister catechist. Sr. Jose is to take over the
programme in the villages and is told by Sr. Mary, that one of
the villages, Serpur, appears to be ready for selecting their
village health worker. Sr. Mary advises Sr. Jose to concentrate
her efforts on this village and see that the people select their
VHV; as soon as possible.
Questions ; Before Sr. Jose can go ahead with the plan what
should she know 9
Once she decides to go ahead what should she do ?
Sr. Jose started regular visit to the villages and gave
special care to Serpur. She took time to meet the leaders and
the per'le of the community and discussed with them the need
for change and the important function of the Village Health
Workers in their community. People and leaders listen but do
not react as positively as expected by Sr. Jose. In fact, they
hardly show any interest in the idea at all.
5 “hat was the reason for this disinterest ?
what should Sr. Jose do ?
2 ..
2
Realising the people's lack of enthusiasm Sr. Jose
smarted vo ask them questions and tm listen to them more care
fully. What was their worry ? ,/hat were their problems ? All
of them were talking of one problem and one problem only; "the
railway tract passes through our village but no train stops here".
If a train could be made to stop in the morhhg on its way to the
district town and in the evening on its way back this would be a
big boost for the development of the village, ^'he milk of the
cooperative could easily be taken to town, the children could go to
high school, products of the village would find their way to town
at a better price.
Sr. Jose went to the district town and discussed this
problem with the railway authorities there. She searnt that, in
fact the railway authorities had already decided to make some of
the trains stop nearby and the plan was to be implemented soon.
Sr. Jose communicated the good news to the village leaders.
After one week, when she visited Scrpur, the village
leader presented her one women who had been chosen by the village
to be the±r village health worker.
Qucst.ipns_.: #hy did the village decide suddenly in one week to
choose their village health worker ?
Comment on Sr. Jose's approach ?
=======_X X X-x = = =: = - = =
Prepared by
Voluntary Health Association
of India, C-14 Community Centre
S.D.A. Now Delhi - 110016.
chtt/la/1-3-84
MICRO LEVEL VOLUNTARY HEALTH PROGRAMME
A Case Study
Village S is situated off the national highway on the main bus route
to the taluk headquarters. It has a population of 3000 people.
The main
occupations of the people are agriculture, sericulture and dairy. A few
families weave carpets out of unprocessed sheep wool. The land is owned by
65 per cent of the families. The plots range from half an acre to twenty-five
acres.
35 percent of the people are landless labourers.
Most of them
are harijans and they live in a separate part of the village.
The village has a primary and middle school, few shrines and a chawki
rearing centre.
The Government health centre (pHC) is 8 kms away and one
of its subcentres is 2 kms away.
cooperative which collects
The highlight of the village is a milk
3000 litres of milk per day and sells it to a
government dairy in the city 45 kms away.
The cooperative provides feed,
fodder, fertiliser, tractor facilities and loans to all its members which
include 45 percent of the families.
Health Programme
1973—75 : A voluntary agency (VA) based in the city and interested in
community health work initiated discussions with the leaders of the milk
cooperative to start a health centre in the village.
As an experiment in
self-support the cooperative agreed to set aside 3 paisa per litre of milk
for health activities.
From the Rs.2400 - 2700 that was available each
month through this scheme, the VA assisted the cooperative in identifying
a doctor and nurse from the city to work in the centre.
Three villagers were
identified, to be trained informally as record clerk, compounder aid dai.
The health cooperative (HC) was run by a committee which consisted of
leaders of the milk cooperative and representatives of the VA, government
dairy and PHC. The doctor was the secretary of this management committee.
It met every month to assess and plan the work of the centre.
The HC rented out an old hotel
the staff.
for the centre and-some accomodation for
Medicines were brought at wholesale rates from the city. Tonics
and injections were stocked to prescribe to non-members and supplement the
income of the centre. Some medicines, vitamins and vaccines were tapped
from the PHC. The VA provided technical advice and- obtained donations
of medical equipment and a motor-bike for the doctoy from foreign donor
agencies.
He provided curative services through a daily c^ini^. Preventive and
Promotive services which included maternal and under-five'child care,
immunizations, vitamin and iron supplementation, chlort-Sation of wells and
film shows were also organised.
Curative services wepe available free to
Preventive services
members while non—members had to pay
a nominal cost.
were available to all free of charge.
Poor non-members families were
given concessional or free treatment depending on their situation.
Committee agreed to set aside Rs.200/- per month for this purpose.
The HC
2
~
~
The doctor and his wife started a Mahila Mandal which organised a
balwadi, child feeding programme and obtained a sewing machine for the
village women.
A young farmers club was also started which organised games
for village youth and helped the centre during immunization, health • u
education
programmes and specialist camps.
1976 : The cooperative Stopped setting aside Rs.200/- per month for
concessional treatment for poor families... The VA took up this responsibility
The doctor left the centre after differences of opinion with the leaders and
started private practice in a neighbouring village. The VA helped the centre
to identify another doctor.
The Mahila Mandal closes down and the.
sewing machine is kept by a pc.nchayat leaders wife.
1977: The nurse left the centre after ...training the dai in all aspects of the
centre's work.
The committee tried to find a replacement . but ultimately
decided to appoint the trained da_ as the 'nurse' of the centre. Committee
meetings were held once in 3-4
. .'.-bss
1978 : The milk production in the-village catie'down drastically while
sericulture increased in the O‘"eu- The health cess per litre, became too
high to run the basic, health services. Since it was difficult to
cooperatise sericulture the milk cooperative after some hesitation
invested some money it had kept aside for a chilling plant, into a fixeddeposit endowment.-for the health centre/
Because of the increase in sericiG ture, landless harijan families
began to get more work and m-.ny acquired a local milch animal. They tried
putting some milk into the common pool to get nembership status and free
health facilities. The cooperative committee closed membership to keep them
out.
1979: An evaluation was dene to study the impact of the centre. It found +
that though all f .~:..:iliei were aware
of the ce?itre, some of them did not
utilise, its services, t ne richer families preferred private practitioners
in neighbouring villages
Many landless families had apprehensions about
theattitudes of some of the staff. Triple antigen and polio immunizations
had been given to 35 percent of the children. Malnutrition and Vitamin A
deficiency had not improved - in fact there were indications that it had
become, worse -
There w.'.s no change in environmental sanitation. The centre
did no family planning work, because of the church connections of the VA.
1982; The centre got its fourth doctor since i977>
Each of the previous
ones had stayed for periods .ranging from few months to two years / with the
help of go-remment subsidy and some cavings the cooperative also built a
health centre and medical officers quarters.
The VA donates furniture
and more equipment to the centre.
Task: 1. What arc- your impre.
-s.'fdns
*
abut this health programme ?
2. Formula.;e questions which will help you to evaluate the approach
and efforts of this acaith programme.
L;CO: S--./-.RMIWG I-ROGRAF.'. E
Sr.Lucy loves the poor, feels committed to them and has the
real to work for them. Earlier she was in a town community
where she was able to help the cycle richshaw wallas to
own richshaws through bank loans instead of hiring from
rich people who owned 100-150 rickshaws. With this exper
ience she came to the village Russelpura.
In Russelpura she had with her Sr.Leela who was equally
committed to the cause of the poor. Together they went to
the village and spent time with the people. The sisters
found that most of the villagers worked for daily wages and
the income was not sufficient to meet the daily needs. Since
the people had to go to work everyday, there was no proper
care given to the children or to the surroundings of their
houses. The sisters reasoned the major problem here was
economic and if the menfolk could get some occupation which
brought them enough money,
'^hen the womenfolk will not have
to go out for work and thereby more care could be given to
their houses and the children will be healthier.
The sisters applied to Church Agency for the Poor(CAP) and
got funds sanctioned for income earning programmes in the
village. A village meeting was convened. The sisters explained
to the group the necessity of unity and mutual concern. She
also explained the economic benefit schemes.
First 10 people
will be helped to start some income earnings programme.
This will have to be repaid and repaid amount will be given
to another 10 people.
A village committee was sent up to select the 10 people who
would be helped first.
So 10 names were suggested by the
committee and money was distributed.
As months passed it was observed that the income of the 10
increased and thereby their standard of living.
It was also
observed that the milk of the cows bought with the money was
sold in the village at a higher rate. The man who started
provision store was charging a higher price from the villag
ers. Two people who got the money used it to give loans at
an interest rate of 60% to the villagers. The repayment was
prompt for two months.
Slowly one by one stopped repaying
and within six months none of the ten were repaying their dues.
The income earning programme could not progress further and the
sisters sat down and analysed the situation.
They felt they
failed and they would adopt a different strategy.
KL:19/9/1986(200)
Catholic Hospital Association of India
'
C. B. C. I. Centre, Goldakkhana, New Delhi- 110001
Tel. 310694, 322064
THAKURPUR
CASE STUDY ; ...FREE GIFT TO PEOPLE OR NOT ?
For the past six months, two health workers have been
working in Thakurpur village. During these months, they met the
village people and tried to identify their main health problems.
At the end, the health workers concluded that the people of
I'hakurpur were not really concerned about their health and were
resistant to any changes suggested to them by the health workers.
For instance, even though malnutrition was such a problem
in the village children, nobody accepted to change the children
feeding habits and the age of starting weaning food and despite
repeated health talk and advice given during the home visits.
Some of the people had expected the health workers to give
them something free and in fact, the health workers had. discussed
between themselves the possibility of dealing with the malnutrition
problem by distributing free food to the children under five years.
One of the health workers, Chandra, felt that food distribution
would certainly same some of the chidrcn lives. But the other
workers felt that food distribution would create difficulty in the
community, alienate the people and at the end, the evils such
distribution would bring, wiuld be greater than the benefits.
Chandfa, then pointed out that when distributing food they would
be able to give good health education to the mothers and thus
bring the hoped for changes in the feeding habits of the children.
s Can you help them to solve their dilemma ?
1.
what do you think is probably the most important reasons for
under nutrition of those children ? Why are the people so
reluctant to change their habits ?
2.
Should we use free gifts in order to develop the people ?
Explain your position ?
3.
If the answer to the previous question is YES, what could be
the unexpected effect of a MCH programme fully based on food
supply from foreign countries ?
■=«====_x_X_x_===~===_x_X _x_=======
Prepared by
Voluntary Health Association
of India, C-14> Community Ccntr
S ,D .A . New Delhi - 110016.
chtt/la/3-3-84
MARIAPURAM CASE STUDY
Sr.Kamala is an experienced nurse, working in a dispensary.
Since she could not find time to visit the villages, she
appointed Shanta and Lakshmi to help her to carry out the
village programmes. They should assist Sr.Kamala in the
morning 8 to12 in the dispensary and go to the villages
in the afternoon.
by 6.50.
They had to be back to the dispensary
Both the girls strictly kept up the schedule.
During the village visits, they could not meet many people.
Sr.Kamala was annoyed at the people because they were not
coming together. At that time CRS became available.
Sr.Kamala decided to start CRS MCH Programme in the village
so that she could conduct immunisation and health education.
CRS help was sanctioned.
With enthusiasm they explained the programme to the villagers
and put down the following rules?
1.
Mother should come to the centre with the child.
2.
Registration fee will be Rs.5/- and monthly collection
will- be Rs. 2/-
3.
4.
The distribution of food stuffs will be twice a month.
The children should be. weighed once a month.
5.
The mothers should bring their child's growth chart
every time they came.
6.
Every child should undergo immunisation.
7.
All mothers should attend health education classes.
In the beginning the programme went on well.
.Slowly the
number of mothers for health education decreased. Sr.Kamala
also found that only 10% of the total number of children had
been immunised within six months of starting the programme.
Sr.Kamala was very much discouraged at the lack of co
operation from the people and blamed Santhamma and LakShmi
for this. She decided to discontinue village work for the
time being.
VALUES & VALUES (F)
Miss Sumati was from a very poor family. She lived in
a hut near the bank of a river. She was in love with Mr. Sunil,
who lived on the other side of the river, and was also from a
poor family. This love affair was known to both the families.
Ome day Sumati heard that Sunil is seriously ill. It was
monsoon time and the rivor was overflowing. She had to cross the
river by a country boat. But she had no money to pay the boat man.
She approached Suresh, her neighbour to borrow some money, but
he refused to give. She then met Shankar, the boat man and ex
plained to him the situation, and assured him that she will pay
him the boat fare later. Shankar insisted that only if she
pays the boat fare (rs. 2/-) he will take her to the other side
of the river. She pleaded with him and told that her lover is
seriously ill, and that she must meet him immediately
*
Shankar
told her that if the matter is so urgent he will take her to the
other side on the following day provided she is prepared to
sleep with him that night. When Sumati realized that arguments
were of no use she agreed to the condition.
On the following morning Sunati reached Sunil's house, and
in the course of their heart to heart talks, she narrated the hard
ships she had to go through inorder to meet him. Sunil got a
shock of his life when ho realized that Sumati is no more a
Virgin, and in his anger he beat her and chased her out of the
house. Sumati returned home very sad and frustrated.
When Sathish, her brother asked Sumati the reason for her
sadness she told that Sunil rejected her and she was ill treated
and beaten by him when she visited him at his sick bed. Infuriated
by this Sathish rushed to Sunil's house, pulled him out of his
bed and killed him.
Who is the most virtuous character in this story? Why?
Who is the worst character in this story? Why?
17/11/1987.
t. j./l.k.
200. C.
Community Health Department
Catholic Hospital Association
of India, P.B.2126,
Secunderabad - 500 003.
RAMAKK'S STORY
Ramakka, wife of Veerabadrappa has two children.
She goes
to work in Periaswamy's field for the wage of 1 rupee a day.
Her younger son, Linga, only 11 months old, got diarrhoea
which is a common problem leading to death in the village.
With one rupee which she got as that day's wage, she bought
50 paise worth of powder medicine from the nearby petty shop.
50 paise worth of flowers she offered in the temple for
the cure of her son.
As the diarrhoea continued she approached
the local Dai Yellamma for help.
She gave her some herbal
medicines. But the situation became worse and so
Ramakka,
with the money her husband borrowed, took the child to the
local doctor, who has no training but some knowledge received
by watching his uncle who was a compounder.
He gave an
injection worth Rs. 7/-. The chi^d got temporary relief.
When the sedation power of the injection got over, the
diarrhoea started again. The local Dia, advised Ramakka to
take the child to the district hospital 20 Kms away. She
borrowed Rs. 20/- from the money lender on the condition that
the amount with the one third of it as interest will be paid
pack in paddy, during the harvest season.
Thus they reached the hospital. She was ignorant of the
proceedures of the government hospital. She had to give Rs. 2/to the gate keeper for entry.
so busy
The hospital personnel were
that they could attend to the child only very late.
They scolded Ramakka for the delay in bringing the child for
medical care. She could not tell the doctor that their trip
cost her three week's pay which she should pay back with
interest. The doctor also scolded Ramakka for not bringing the
child early, and furiously wrote a long prescription including
four I.V. fluids. The pharmacist billed her Rs. 60/-. But
Ramakka did not have that much money. She bought few tablets
and returned home. While on her way back home, the child
breathed it's last on Ramakka's shoulder.
**********
EXERCISE
IN
COWUNICAT IONS
B. MANOJ GUPTA
Manoj Gupta is a devoted artist running a studio in the
City and according to him, his life-long ambition has always been
the creation of a piece of art that will be of eternal value.
He wanted to give expression to a female form that will surpass
Venus.
And he was on the look out for a model for achieving
this ambition. He used to visit all places where he could find
beautiful ladies, but nowhere could he find the form that he
had in mind. Then one day...(the same scenes that we saw
earlier follows with Manoj 's commenrs put 'in brackets).
Scene (1)
Manoj was sitting one evening in a restaurant with a
girl friend. An extremely beautiful lady appears at the entrance
along with a gentleman; they occupy a table at the ether end of
the hall. Manoj is enchanted with the beauty of the lady (l
realise that at last I have found the form that I was searching
for long) and he becomes restless.
For the moment, he forgets
the fact that he is in the company of a djirl friend and he doesn't
even listen to her. Growing impatient, he brushes aside- the
girl friend and walks over to the other end of the hall where the
beautiful lady and the gentleman were sitting.
He says "Excuse me"
to the gentleman and beckons the lady to rise up and come to him.
They go together to the- lobby and he whispers something in her ears
to which she nods.
(I requested her to act as my model; she agreed.
I fixed an appointment with- her at my studio at Q.00 am the next
day.) They come back, the lady goest to the gentleman =nd Manoj
comes back to his old seat. Being restless, he could not remain
any longer in the restaurant; he takes the hand of the girl
friend and they walk out of the restaurant.
One of the two
waiters, who were watching all this, tells the other: "What a
woman-hunter?"
Scene (2)
Next morning Manoj gets up early from the bed and putting
on his dress hastily rushes out of the house.
Mother brines a cup
of coffee and requests'him to take coffee before going out.
He
brushes her aside- saying "I have no time now; I have an appointment
to keep."
Without listening to the- repeated entreaties of his
mother, he hurries down the stairs anc out into the street.
(I did not mean any disaffection towards my mother; I only wanted
to get to the studio in time). The mother wails: "What has happened
to my Manoj who was such a good boy?
He has been moody and difficult."
... .2
2
Scene- (3)
Out in the street, he spots out a taxi, but the- driver was
talking in the telephone booth nearby. Manoj requests him to come
away, but the man continues to talk. Growing impatient, Manoj
bawls out at him to hang up and come away. The driver is stunned,
but he hangs the phone and comes back.
('"Once inside the taxi, Manoj pulls out a pad and begins
making line sketches of the post, form and other details of presentat
ion of the great piece of art that he is going to create. He draws
one one sheet, then rears it off and tries another.
Like this, he
makes a number of trial sketches and he is deeply absorbed in the
thought of how to give expression to the idea that he was carrying
in his mind for long.?
Curing the drive, as is usual with all taxi drivers, he talks
about the weather, last night's crimes in the city and petty
politics. Manoj tells him that he is not interested in any of these "
and that he wants to have a quiet time. The taxi driver chuckles
thinking what sort of a man is this. Unable to resist the temptation'
after a while, he again resumes his talk.
Manoj becomes furious and
thumps him .first at the back of the seat shouting "shut up". The
driver becomes mortally afraid to open his mouth again. After
leaving Manoj at the appointed place, he wonders, "What a rowdy?"
Scene (4)
Getting out of the taxi as Manoj was entering the building,
the landlord stood at the foot of the stairs and wished him,
"Good morning."
(He is a terrible bore and if I allow him to have
his way, I would be delayed at least half an hour.
So, I decided
0
to play foul with him.).
Manoj runs into a fury and, catching him
by the collar, asks him: "What did you say? Good morning? It may
be good morning to some, may be bad morning for others.
What the hell
do you want with me?" The man is completely taken aback and wonders
loudly, after Manoj had gone up the stairs: "What a lunatic?"
Scene (5)
Inside the building the Janitor woman notices Manoj coming
much earlier than usual and getting into his room.
Shortly after
wards, she also sees a beautiful lady coming up the stairs and
going into Manoj’s room.
She could not help smiling meaningfully.
3
3
As the lady knocks at the- door, Manoj comes and opens the
door. He removes and hangs up her coat. • After requesting her to take
the seat, he bees her pardon for making her wait for a little while
and arranges the drawing board, dishes, colours, etc. Then he walks
over to the lady stil? holding the rod of the stand in his hand
and directs her to pose for the model.
Instead of posing as directed,
she makes overtures to him.
Manoj gently tric-s to make her sidl
down telling her that after the work is over, they will have a nice
time together.
But, she continues with her flirtations with him
in a more and more passionate manner in spite of all his entreaties
to let the work be finished first and after a while she tries to
put hands around him and embrace him.
Losing all hope of doing
the work and feeling frustrated with the shattering of his lifelong
ambition, he pushes her hand against the sofa and she screams aloud.
The janitor woman hears a scream from the room. She rushes
up, opens the door and sees Manoj with an iron rod in his hand
and the lady lying motionless on the sofa
*
She jams the door
shouting, "Murder" and frantically runs away.
& 8. &
Now what do you think' of Manoj?
summarising his character).
4
* *
(Give a one-word expression
THE CATHOLIC HOSPITAL ASSOCIATION OF INDIA
Community Health Department
Grams
CEEHAI
SECUNDERABAD 500 003
Telephones :
Telex
:
S4S2 93, 84 84 57
0425 6674 CHAI IN
Post Box 2126
157/6 Staff Road
SECUNDERABAD 500003
CASE STUDY ; YESHUBAD
Fr. Ashok was a nice person, gentle, kind and always ready
to help others. He was intelligent and loved people very much. He
was concerned about many of the problems that the village people
faced and wanted to do something to help them.
One of the needs of the village was a school. There was no
primary school within 5 kms. of Yeshubad. Therefore the children
remained illiterate and ignorant. So father opened a primary school
with facilities up to Ilnd standard primary education,It was a free
school, admission being restricted to Yeshubad village people
only. He was himself the principal and teacher, and Seminarians
passing through also helped sometimes. With the geneous food
supplies gifted by Excess Relief Supplies Inc.(ERS) USA, Father
was able to distribute free school lunch to all schoolmates.
This attracted more and more parents and children. Within the
first two months the school had 170 children on its register.
After six months, ERS stopped supplying any more food due to un
avoidable circumstances. Father had to stop distributing any school
lunch. The parents got upset and some of them were very angry.
Slowly they started taking out their children one by one till
only 10 children were left"on the school's roll. The parents said
loudly to each other "What is the use of learning and reading so
many books, anyway. That doesn't help. Nor does it feed empty
stomachs. Det the children go to.the field, help their elders,
learn some practical and useful wAPSS fills their stomach", it was t
the harvest season. (Later on it was found that out of the 10 remaini
ining students, 6 were the children engaged by the Parish.They
kept their children in the school as they thought,.it would please
father.)
Father very soon closed the school. He felt let down ahd
damoralised. Within a few months Father regained the—enthusiasm
and decided to start a housing scheme as this was another need
of the people. Hardly any one had a nice house in Yeshubad except
the landlord Sarpanch, and himself. People lived in cramped,
filthy, unhygenic houses with no windows. With ERS' donation he
built 20 houses for a few of the Yeshubad villagers. The houses
were nice and spacious with concrete roofs. They were well venti
lated with huge windows. Each flat was an independent unit and
had one living room, a kitchen and a toilet.
Except for the 20 lucky families receiving free houses,
others were bitter and angry.. They felt Father was partial to them.
Father explained to the people arc that he had money only to
build 20 houses. The people felt that the Father could have got
more money. That summer father took some guests to see the new
houses. The guests, to their surprise, found that the houses were
not being used ascplanned. Most of the families had converted the
kitchen room to store grains, household rubbish etc. and the
living room was used as a good cattle shed. All the windows
were sealed with stones. The toilets had no tap water facilities.
People felt that it was a dirty thing, to have a toilet right
inside the house and that too without any water. The families
-2-
explained: "Wo love to live in the open, wo are strong and can 1
bear any weather. But the cattle cannot. They are poor dumb
animals, precious to us and need such great care. Also our
grain is precious, so we have sealed the windows to keep it
safe from thieves, Trab is why our cattle and grain is inside
while we live happily under the clear open sky".
"But what about the small children?" - Father asked.
"Oh Fatherji, they are .Farmer's kids. If God wills to take
one. He will give another little one. "
Community Health Department
of Catholic Hospital Association of India
Secunderabad-50000 3,
18-1-1988.
200 copies.
Ik.
SETTING GOfr,LS
(Training paper VIII)
Most of us live and work far below our capacity, we are
like bits of wood, floating passively on a.river.
he are
carried here and there by the currents of the river without
any aim of our own.
•
•
Setting goals for ourselves can free us from tne aimlessness
and inertia of floating on the river.
Goals can help to give
meanin;.. and direction to our lives.
They can help us to use
our c apabilities more fully and effectively.
They can- help us
to develop our potentials.
They oan help us to use our
resources, our time, and our energies more effectively.
They
can guide us when we have to take decisions and make plans.
They can help us to change ourselves.
They can help us to work
for change in society.
research has shown th t commitment to clearly stated goals
leads to the achievement of these goals.
yet this commitment
is not acquired easily.
Commitment to personal life-goals can
be especially costly.
To choose one goal is to reject others.
you can't be a development worker and a businessman too.
Further, once we set goals for ourselves, we must have the
courage to risk failure in reaching those goals.
One who sets
no goals for himself does not run the risk of failing to
reach his goals.
Often we confuse activities-doing things-with achieving
goals,
he invest ourselves and. our own resources (our time,
our capabilities,'-our efforts, our commitment) into activities
(work, talk, journeys, visits, leisure,- social events, training
or whatever it may be) without thought for the end-result of
such activities.
Unless the end-result is clear,, the purpose
of the activities may not be clear.
setting goals, which are
the end-results we want to -achieve, can bring purpose and
meaning to our activities.
To be able to set meaningful and attainable goals, we must
know ourselves,
what do we do best? khat do we enjoy doing?
khat are our strengths? How can be build on our strengths?
How can we change ourselves?
■ -■
If we want to change ourselves-ti acquire and practise
new skills, or to behave differently-goals can help us.
For
one thing they help us to compare what we want to do with what
we actually do now. They also, in themselves, help to motivate u&
us to achieve the changes we want, and they reinforce our
efforts to change. Goals that are associated with an enahanced
self-image will help to motivate us further.
Our goals must be challenging.
If they are not sufficiently
challenging-ro . if we are not going to make the necessary
efforts-there is no point in getting goals,
we might as well
continue as we are doing already.
On the other hand,we must be realistic in a:etting goals.
We must assess our opportunities and situation carefully.
What goals would be realistic and within our reach?
If we set
unrealistic goals, we shall not be able to achieve them, and
this will lead to frustration and disappointment.
Moreover,
once we have- <set goals, we must have enough self-confidence
to reach out towards them.
If we feel our situation te be'
hopeless, our go al-setting will be in a vain- and will again
lead to frustration.
.2,
The Catholic Hospital Association of India
C. B. C. I. Centre, Goldakkhana, New Delhi - 110001
Tel. 310694, 322064
ARGOT ...OfaSD STUDY..... (Y.p.M.^
Mr. Sunder was a social worker, working in a Community
Development Programme in Arcot district. He was interested im
improving the health status of the people. He understood well
that the problem of ill health was mostly related to the low
economic status of the people and the best way to solve th
* s
was through economic development with people's participation.
The main problem in his village was water for irrigation.
Although most of the families had some land, the produce was very
little and the food was not enough for all the villagers.
Mr. Sunder visited the sarpanch of the village and discussed
this problem with him. The sarpanch was very happy to hear about
Mr. Sunder's plan for water development. The sarpanch called for a
village meeting the next day in which Mr. Sunder was allowed to
present his plan. The plan was to build a large tank to help
collect the rain water. As the people were very poor, he proposed
that the village contribute free labour and the building material
would be provided by Mr. Sunder's agency.
The site was c’ men and the work started . After two weeks
Mr. Sunder noticed that the number of people working at the sitewas
decreasing. As the days went by, more and more people dropped out,
Mr. Sunder was unable to find way any reason for this. Finally,
only a handful of people were left.
=-—-----x"X x------ -----
Questions :
1.
a. Why, do you think did the people drop out of the programme
as they did ?
b. Who, do you think will benefit if the tank is built ?
2.
Comment on Mr. °undcr's way of dealing with the problem ?
3-
If, in your area water is the need, what information
would you need before taking up any definite programme ?
chtt/la/1-3-84
Prepared by
Voluntary Health Association
of India, C-14 Community Ccntr-.
Dtihi - 110016;-
8
IMAGES
La zy
Ins ecur e
Impersonal
Dependable
Conservative
Progress!ve
Mat ure
Emotional
.'Un common i cat ive
Uncooperat ive
Rest loss
Helpful
Professional
Erust rat ed
Concerned
Irresponsible
Confussd
Backward
Ent husiastic
Dogmat ic
Hard-working
Money-minded
Efficient
Immat ure
Loyal
Insincere
Idealistic
Undependable
Over-productive
apathetic
Encouraging
Risk-taking
Responsible
Supportive
gel f- co nt ro1led
Unprofessional
Over-sensitive
Impulsive
Appreciative
Sup crficial
Naive
Exploit ed
"1.
Erom the list of adjectives given above, which seem to you best
to describe the urban worker?
Select as many words as you wish.
If
you wish to add one of yotar own, feel free to do so.
2.
from the same list, which adjectives seem best to you to des
cribe the unemployed?
3
From the same list
which adj cct i ves seem best to you to describe
the villager?
i.
4
From the same list
which adjectives seem
cribe the average student?
best to you to des-
-2-
5.
From the same list, which adjectives seem best to you to des
cribe your parents?
6.
From the same list, which adjectives seem best to you to des
cribe yourselves?
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