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PROGRAMME EVALUATION
BASIC HEALTH SERVICES INDIA
DESK STUDY
CEBEMO / ICCO / DGIS
(programme evaluation 60)
DRAFT DOCUMENT
(for internal use of evaluation mission only,
quotations and multiplication not allowed)
Public Health Consultants
Dik Roth Msc. Anth.
in collaboration with
Dr. Mariette Wiebenga
Dr.Ravi Narayan
Overall responsibility:
Erik Heydelberg Msc.
October 7 1994
Amsterdam
Netherlands
mil ii mi
0
Fc
advies, onderzoek en ontwikkeling in de gezondheidszorg
Dr. Ravi Narayan
Academic Research Visitor (THEO/EPS)
London School of Hygiene and Tropical Medicine
Keppel Street (Gower Street)
LONDON WC1E 7HJ
England
Amsterdam, October 13, 1994
Dear Ravi,
Thank you very much for your valuable contribution to the deskstudy "Evaluation
basic health services India".
We have integrated your chapters in the document. I enclose a copy.
The status of the document is that of a working document for the mission. After the
mission parts of it will be used in the mission report.
I would very much welcome any comments from your side on the document as it is
now.
Hope everything is fine with you and hope to work with you once again.
Yours sincerely,
(_ (\Aa . E,
Lcxxveol,
)
Erik Heydelberg
Encl. : deskstudy (1)
Keizersgracht 212
1016 DX Amsterdam
The Netherlands
Tel.:+31-(0)20-6264298
Fax:+31-(0)20-6385579
Suderein 40
9255 LC Tietjerk
The Netherlands
Tel.:+31-(0)5118-32146
Fax: +31-(0)5118-32135
advies, onderzoek en ontwikkeling in de gezondheidszorg
PROGRAMME EVALUATION
BASIC HEALTH SERVICES INDIA
DESK STUDY
CEBEMO / ICCO / DGIS
(programme evaluation 60)
DRAFT DOCUMENT
(for internal use of evaluation mission only,
quotations and multiplication not allowed)
Public Health Consultants
Dik Roth Msc. Anth.
in collaboration with
Dr. Mariette Wiebenga
Dr.Ravi Narayan
Overall responsibility:
Erik Heydelberg Msc.
October 7 1994
Amsterdam
Netherlands
I’
Keizersgracht 212
1016 DX Amsterdam
The Netherlands
Tel.:+31-(0)20-6264298
Fax:+31-(0)20-6385579
Suderein 40
9255 LC Tietjerk
The Netherlands
Tel.:+31-(0)5118-2146
Fax:+31-(0)5118-2135
TABLE OF CONTENTS
INTRODUCTION
2.
1.
THE STRATEGY OF PRIMARY HEALTH CARE
4
1.1.
1.2.
1.3.
1.4.
Introduction
The concept of primary health care
Between Alma Ata and the year 2000
Challenges for the future
District health care
A.
Urban health care
B.
Gender aspects of health care
C.
Intersectoral cooperation and NGO's ...
D.
Future allocation of health resources .
E.
4
5
8
12
13
14
14
15
16
INDIA: A GENERAL COUNTRY PROFILE
17
General characteristics
Recent political developments
Economic development
Some areas of priority
The position of women
A.
Urbanization and the urban poor
B.
Scheduled tribes and castes ...
C.
2.5. NGO's in India
17
19
20
21
21
22
24
THE HEALTH SECTOR IN INDIA
25
3.1. Introduction
3.2. Recent political and administrative deve
lopments relevant to the health sector
3.3. Health and the voluntary sector
3.4. The population profile
3.5. Health status and health problems
Some general data
A.
Communicable diseases
B.
Non-communicable diseases
C.
Other major problems
D.
3.6. Primary health care services and national
programmes
Primary health care services
A.
National programmes
B.
3.7. Population, development and family welfare .
Population and development programmes .
A.
Family planning (welfare) programme ...
B.
3.8. Supportive services and structures, and
additional sectors
Human power planning and health team
A.
training
General practice
B.
Secondary care services
C.
26
2.1.
2.2.
2.3.
2.4.
3.
1
27
28
28
29
29
31
31
32
33
33
34
34
34
36
37
37
37
38
Tertiary care
The private sector
Research institutes
University linkages of health team
training
National health service
H.
Occupational health
I.
School health
J.
3.9. Health finance
3.10. Traditional systems of health care/ISM
3.11. Voluntarism and health care alternatives ...
3.12. National-level voluntary organizations
3.13.International funding agencies
.......
3.14.Issues and challenges in health policy.
A.
Recent developments in health policy ..
B.
Two continuing challenges
3.15.References to chapter 4
38
38
39
DUTCH DEVELOPMENT POLICY AND INDIA
51
4.1 . Dutch bilateral development cooperation
with India
.....
4.2. Cebemo: general development policy ....
4.3. Cebemo in India
....
4.4. Cebemo: health policy
4.5. Icco: general development policy
4.6. Icco in India
4.7. Icco: health policy
51
53
55
56
58
60
61
PROFILES OF ORGANIZATIONS, PROJECTS AND
PROGRAMMES FUNDED BY CEBEMO
62
D.
E.
F.
G.
4.
5.
5.1. Introduction
5.2. Bengal Rural Welfare Service (BRWS), Cal
cutta, West Bengal: Programme for Rural
Basic Health Care
...........
Village
Health
Workers
Scheme,
Diocese
of
5.3.
Berhampur, Orissa: Diocesan Training Center
and Programme of Rural Health Workers,
Jaganathpur village
.....................
St.Thomas
Mission
Society,
Mandya, Karnataka:
5.4.
Community—Based Health and Development
Programme
..............
5.5. Karuna Social Service Society (KSSS), Diocese
of Bijnor: Community Health Programme
5e6. Peermade Development Society (PDS), Kerala,
India: Integrated Health and Development
Programme
5.7 . Trust for Reaching the Unreached (TRU),
diocese of Ahmedabad, Gujarat: programme for
Comprehensive Primary Health Care
5.8. Christian Council for Rural Development and
Research (CCOORR), MAGR District (Vengal),
Tamil Nadu: Rural Health Training Center and
39
39
40
40
40
42
43
45
46
47
47
49
49
62
63
68
73
78
81
86
Extension of Field Activities
6.
PROFILES OF ORGANIZATIONS, PROJECTS AND
PROGRAMMES FUNDED BY ICCO ............
6.1. Introduction ..........
6.2 Child in Need Institute (CINI), Calcutta,
West Bengal: Integrated Development Programme
for the Women and child in Need ........
6 3 Ashish Gram Rachna Trust/Institute of Health
Management Pachod (AGRT/IHMP), Pachod, Maha
rashtra: consortium project AGRT/IHMP ••••••
6.4. Voluntary Health Association of India (VHAI),
New Delhi: programme financing 1992 '95 ....
6 5 Christian Medical Association of India
(CMAI), New Delhi: consortium financing
1993-1996 ................. ..........
6.6. Rajasthan Voluntary Health Association
(RVHA), Jaipur, Rajasthan: support to RVHA
programme 1993-1997 .............. ’’?•
6.7. International Nursing Service Association
(INSA), Bangalore, Karnataka: Rural Health
and Development Trainers Programme,
1991-1994 ....................
.
Asian
Community Health Action^Network
6.8
(ACHAN) , Madras, Tamil Nadu: Community-Based
Action for Transformation in Asia ...
7.
RECOMMENDATIONS FOR SELECTION OF THE EVALUANDUM
7.1. Introduction
7.2. Recommendations: Cebemo
7.3. Recommendations: Icco .
NOTES
REFERENCES
ANNEX 1:
HEALTH PROJECTS AND PROGRAMMES OF CEBEMO
ANNEX 2:
HEALTH PROJECTS AND PROGRAMMES OF ICCO
ANNEX 3:
SELECTED STATISTICAL DATA ON INDIA
ANNEX 4:
SELECTED STATISTICA1 DATA ON HEALTH AND
HEALTH CARE IN INDIA
94
94
96
101
105
110
114
118
121
124
124
128
MAP OF INDIA
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States in which the Netherlands
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(Reorganisation) Act 1971, but has yet to be verified.
•Responsibility for correctness of internal details shown on the map rests with the publisher.
INTRODUCTION
Cebemo (Catholic Organization for Development Cooperation) and Icco (Inter-Church
Organization for Development Cooperation) are two of the four Dutch Co-Financing
Agencies (CFA’s; the other two being Novib and Hivos). Through these organizations part
of the Dutch government budget for development cooperation is channeled to non
governmental partners in developing countries. In 1965, Cebemo (actually, between 1965
and 1969 this function was fulfilled by CMC, Centraal Missie Commissariaat) and Icco
were established and started to channel Dutch development funds to their counterpart
organizations in developing countries (followed in the seventies by Novib and Hivos). In
1965 the Dutch Government allocated Dfl. 5 million to the co-financing programme.
Since the seventies all CFA’s have experienced an enormous growth, both of the
organizations themselves and the budgets allocated to them, and of their number of
counterparts. In 1990 the four CFA's financed about 5.500 projects and programmes in
104 countries (Impactstudie Medefinancieringsprogramma, 1991). In 1993 a total of Dfl.
418 million (6,75% of the total budget for Dutch development cooperation) was allocated
to these organizations. From 1994, 7% of the national budget for development cooperation
is allocated to the CFA's (Begroting Ontwikkelingssamenwerking, 1994).
Before 1980, each project proposal had to be approved separately by the Government of
the Netherlands. However, in 1980 the block grant system of the Programme Financing
Agreement was introduced. This new agreement gave the CFA’s greater freedom to
implement their programmes, but also a greater burden of obligations related to
accountability. From 1980 evaluations, inspections, financial control, annual reports and
policy documents became the main instruments for (retrospective) periodical control. The
Programme Financing Agreement was extended in 1984, 1988 and 1993.
One of the themes for the programme evaluations planned for the period 1993-1995 is
'basic social services' (primary health care and education). In preparing their programme
evaluation in India, Cebemo and Icco have decided to concentrate on the theme of 'basic
social services', and, more specifically, health care, in view of the considerable support
provided to activities in this field by both organizations.
In recent years, the NGO 'sector' in India has experienced an enormous growth, both in
coverage and scope of activities, and in the number of NGO's active in the field of
development in general, or health care in particular. While a large number of these NGO's
continue to concentrate on local implementation of projects and programmes, an increasing
number of NGO's are taking up other activities not directly related to implementation:
training and support, advice and evaluation, lobbying and advocacy, representation and
provision of other services.
During the last few years, policy changes related to these new developments in the Indian
NGO world have become visible among the Dutch CFA's. While Icco has 'scaled up' and
shifted its support from implementing organizations at local level to a diversity of support
organizations at higher levels of administration (federal state, national), Cebemo continues
to prioritize support to local implementing organizations.
1
However, until now little is known about the nature of the relationships between
implementing and support organizations, the quality of support and other services provided
by intermediary
support -, and umbrella organizations to implementing organizations,
and their impact on the quality of the activities of the implementing organizations.
Therefore, it was decided to make the relationship between regional, state or national
support organizations and local (village, block, district, diocese) implementing
organizations the main theme of this programme evaluation. This relationship will have to
be assessed in the light of the existing health care 'system' and the health care policy of
the Government of India, the health services provided by the government and the private
sector, and the changing health needs, demands and expectations of various sections of the
population (including the middle and higher classes).
Key questions for this programme evaluation, as given in the concept TOR are:
1.
2.
3.
4.
What is the contribution of support organizations, active in the field of health
care,towards the strengthening of the work of (member) organizations
implementing health programmes directed towards the poor/marginalized groups,
given the health policies carried out by Gol, government institutions and
developments in the private sector?
What are, in view of providing optimal services to the poor/marginalized groups
the expectations of implementing organizations regarding the role of the support
organizations in improvement of the effects and impact of these activities?
What are, based on the above questions, recommendations to the support and
implementing organizations regarding the possible improvement of the quality (i.e.
efficiency and effectivity) of the services offered?
(sic) What are, based on the answers to the above questions, recommendations for
the future support of the implementing organizations, the support organizations,
(by?) Cebemo and Icco to the health sector in India?
The outcome of this programme evaluation should enable implementing organizations,
support organizations and the CFA’s to further specify or adjust their health care policies
in India. Further, possibly the outcome of the programme evaluation will provide an input
into future decisions by the CFA's regarding their health policies in India and the position
of implementing and support organizations within these policies.
In the first chapter of this desk study the concept of Primary Health Care (PHC), as
defined in the Alma Ata declaration of 1978, is discussed. Attention will also be paid to
recent developments in the field of PHC in the light of experiences with policy
implementation, and to future challenges in PHC. The second part consists of a general
country profile of India. Main themes are: general characteristics of India, recent political
and socioeconomic developments, some priority areas for development policy, and NGO's
in India. The third chapter provides a profile of the health sector in India. In the fourth
part, the general developmental policies, India policies and health care policies of the
directorate General for International Cooperation of the ministry of Foreign Affairs
(DGIS), Cebemo, and Icco are described. In the fifth and sixth parts short profiles are
presented of a number of programmes and projects supported by Cebemo and Icco,
preceded by a short introduction on the preselected programmes and organizations. In the
2
last part recommendations for selection will be given, preceded by some additional
remarks on the (pre)selection procedure.
The third chapter of this desk study (The health sector in India) was written by Dr. Ravi
Narayan of the Society for Community Health Awareness, Research and Action in
Bangalore. Thanks are due to Mariette Wiebenga (Public Health Consultants) for writing
I.4.C. (Gender aspects of health care).
Amsterdam, September 1994
Public Health Consultants
Dik Roth
3
1.
1.1.
THE STRATEGY OF PRIMARY HEALTH CARE
Introduction
During the fifties and the sixties 'modernization' was the dominant paradigm of
development. The transfer of capital, technology and scientific knowledge to 'backward'
countries was generally regarded as the key to this 'modernization'. The model for planned
change as well as the final destination of the process of development was, of course,
modern Western industrial society. But from the sixties it was gradually realized that such
modernization and 'trickle down' approaches to development did not work.
Under the influence of new analyses of the basic causes of poverty, the poor came into
view of development planners. The accent shifted from macroeconomic growth to equity
and income distribution. While formerly factors like 'tradition', 'backwardness', 'lack of
initiative' had been identified as causes of poverty and stagnation, in the new approaches
more attention was given to the socioeconomic and political determinants of poverty.
Basic needs approaches gained ground and, from the seventees, target group oriented
development strategies were generally acknowledged as an absolute precondition for
improvement of the situation of the poorest groups, both urban and rural.
The field of health care provides a clear illustration of such changing views of
development. Through the sixties, attempts to improve the health situation in developing
countries had largely been based on the conventional Western model of curative, hospital
based medicine. However, gradually it became clear that the continued allocation of scarce
resources to health infrastructure based on this Western model of health care was not
effective, or even counterproductive. Indicators of health status like infant mortality,
maternal mortality, and under-five mortality continued (and still continue) to be
alarmingly high for many developing countries. Populations of rural areas and urban
slums, who had no access (in a geographical or in an economic sense) to basic health
facilities and essential drugs, continued to die of diseases that are preventable or treatable
at low cost. At the same time, scarce resources went to the ’modern' sector of 'high-tech',
urban-based, curative medicine to serve the health needs of the middle and upper classes
with purchasing power living near health care facilities.
Thus, the conclusion was unavoidable that there was a fatal lack of fit between the priori
ties, delivery systems and services of the governments of many developing countries on
one hand, and the most urgent health needs of the poor majority of the populations of
these countries on the other. Diseases that made (and still make) most victims among the
populations of developing countries (and especially among those groups most susceptible
to them, such as infants, women, and poor and marginalized groups in general) are
diseases of poverty and malnutrition. Basic causes of such diseases are often found in
(socioeconomic, political or cultural) 'environmental' factors rather than in the purely
biomedical sphere. Therefore, apart from its widely acknowledged preventive (e.g.
immunization) and curative virtues, Western medicine, when applied in isolation from
these 'environmental' factors, has little to offer in the eradication of such diseases and
long-term improvement of the health situation.
4
Greater effect is to be expected from an analysis of local health needs and prevailing
diseases within the context of physical, socioeconomic, political and cultural factors that
strongly influence the (local/regional) health situation. Such an analysis may show that
employment and income, nutrition, drinking water and sanitation should be central points
of attention rather than germs or pills.
1.2. The concept of primary health care
General dissatisfaction with the limited effectiveness of the existing health services, and
international recognition of the need to reorient health care in developing countries
resulted in the 1978 WHO-UNICEF Alma Ata conference, known for its policy objective
of 'health for all by the year 2000'.This target was to be achieved through the strategy
of primary health care (PHC). In 1981, the World Health Assembly and the United
Nations General Assembly adopted the 'Global Strategy' based on 'health for all'. Finally,
in 1982, the World Health Assembly approved the plan of action for implementation of
the 'Global Strategy’ (WHO, 1993a).
In the Alma-Ata declaration a central place is accorded to the socioeconomic and cultural
determinants of health. It stresses the importance of identifying, analyzing and combatting
the socioeconomic causes of illness rather than propagating technical and curative
solutions to the health problems of individual members of society. Inequality and poverty
are identified as the main causes of the gloomy health situation in developing countries
and of underdevelopment in general. The need for social justice and equity is central to
the concept of PHC as defined in the Alma Ata declaration. Thus, as Macdonald (1993)
stresses, PHC is not the same as a combination of curative and preventive primary medical
care.
It should be added that PHC was not a new ’invention’. Many of its basic principles were
used, for instance, in India and China. Especially the last country's 'barefoot doctors'
model has laid the foundation for the Village/Community Health Workers (VHW/CHW)
model central to the strategy of PHC. International acceptance of PHC as a long-term
international strategy emanated from a serious concern for the enormous health problems
in developing countries.
For the WHO, the strategy of PHC meant in the first place a necessary adaptation of its
health policy to the economic realities of developing countries, in the light of the
depressing health situation in these countries. Main instruments were prevention and a
maximum of self-reliance (through VHW's providing cheap curative services) (Van der
Geest et al., 1990)
PHC, the central concept of the Alma Ata declaration and the key to 'reaching health for
all', is defined as follows:
Primary health care is essential health care based on practical, scientifically sound
and socially acceptable methods and technology made universally accessible to
individuals and families in the community through their full participation and at a
cost that the community and country can afford to maintain at every stage of their
5
development in the spirit of self-reliance and self-determination. It forms an
integral part both of the country's health system, of which it is the central function
and main focus, and of the overall social and economic development of the
community. It is the first level of contact of individuals, the family and community
with the national health system, bringing health care as close as possible to where
people live and work, and constitutes the first element of a continuing health care
process (WHO/UNICEF, 1978).
PHC should be based on local needs and priorities, on 'traditional' knowledge and health
systems, and make use of appropriate knowledge and technology. PHC 'reflects and
evolves from the economic conditions and socio-cultural and political characteristics of
the country and its communities and is based on the application of the relevant results of
social, biomedical and health services research and public health experience'
(WHO/UNICEF, 1978).
The strategy of primary health care should address 'the main health problems in the
community, providing promotive, preventive, curative and rehabilitative services
accordingly' (WHO/UNICEF, 1978).
Further, in the declaration it it stated that PHC should include at least the following
essential elements:
1.
2.
3.
4.
5.
6.
7.
8.
education concerning prevailing health problems and the methods of preventing and
controlling them;
promotion of food supply and proper nutrition;
an adequate supply of safe water and basic sanitation;
maternal and child health care, including family planning;
immunization against the major infectious diseases;
prevention and control of locally endemic diseases;
appropriate treatment of common diseases and injuries;
provision of esential drugs (WHO/UNICEF, 1978).
The strategy of PHC requires a comprehensive, all-embracing approach to health.
Therefore, it ’involves, in addition to the health sector, all related sectors and aspects of
national and community development, in particular agriculture, animal husbandry, food,
industry, education, housing, public works, communications and other sectors; and
demands the coordinated efforts of all these sectors' (WHO/UNICEF, 1978).
Another important characteristic of the PHC strategy is, that it 'requires and promotes
maximum community and individual self-reliance and participation in the planning,
organization, operation and control of primary health care, making fullest use of local,
national and other available resources; and to this end develops through appropriate
education the ability of communities to participate' (WHO/UNICEF, 1978).
While self-reliance is an important characteristic of PHC, this strategy cannot be
successfull in isolation; it 'should be sustained by integrated, functional and mutually
supportive referral systems, leading to the progressive improvement of comprehensive
health care for all, and giving priority to those most in need' (WHO/UNICEF, 1978).
6
Finally, it is stressed that PHC should rely, both at the local and the referral levels, ’on
health workers, including physicians, nurses, midwives, auxiliaries and community workers
as applicable, as well as traditional practitioners
as needed, suitably trained socially and technically to work as a health team and to
respond to the expressed health needs of the community' (WHO/UNICEF, 1978).
Important as they may be, policy statements like the Alma Ata declaration are sufficiently
vague to allow for the identification of different 'key elements' or 'basic principles' by
different authors or policy makers. Streefland and Chabot (1990), for instance, identify the
basic principles of equity, participation, appropriate technology, prevention and inter
sectoral approach to public health problems. Macdonald (1993) stresses the importance of
promotive aspects, partnership between health professionals and the community, and the
need-orientedness of treatment and curative care. Further, this author discerns three
'pillars' of PHC: participation (community involvement), intersectoral collaboration, and
equity and justice in access to facilities and resource allocation. Tarimo and Creese (1990)
stress availability of essential health care according to need, involvement of communities
in planning, implementation, and evaluation, and intersectoral cooperation.
Finally, some key aspects of the declaration, and their most important consequences for
national health policies, strategies and activities are given below:
First, the central place accorded to the objective of equity in access to and allocation of
basic health care facilities requires a fundamental reorientation of health policies and
consequent allocation of resources available for health care. More specifically, the
objectives of care according to need and providing a maximal coverage of the populations
of developing countries can only be reached through:
a shift from (especially urban-based) middle and upper classes to (rural and urban)
poor groups in society;
a change of priority from curative health care to preventive and
promotive/educational aspects of health care;
a shift of priority from diseases of affluence to diseases associated with poverty.
Second, participation and community involvement are important issues in development
policy in general, and health care policy in particular. With reference to PHC (and
especially the interaction between 'community-based' initiatives and basic health care
provided by the government), one point seems to be of particular importance: attitudinal
changes among health personnel with a 'traditional' (western) health education. Such a
reorientation is a precondition for community involvement and participation in analyzing
the local health situation, identifying major health hazards, decision-making and
evaluation. Without such changes in attitude, other policy goals like making use of local
skills and knowledge will probably remain hollow phrases. In such cases, the rhetoric of
participation and its restriction to implementation and ’delivery' will only lead to 'collective
patient compliance' (Macdonald, 1993). Therefore, 'traditional' status and power
relationship between active, educated health professionals accountable to their superiors or
to nobody at all, and passive, ignorant individual recipients of curative health care should
make way for a new relationship. Key aspects of such a 'partnership' are active
7
involvement of the members of local communities, a relationship based on mutual respect,
and accountability of health professionals to the members of the community. Such a
partnership relation should, of course, also exist between VHW's and health professionals.
Further, there is the danger of VHW's gradually alienating from 'their' communities and
becoming a kind of 'extension workers' (Streefland and Chabot, 1993).
The stress on preventive and promotive (health education) aspects of health care requires a
reorientation of health agencies and services, a reallocation of health resources, health
personnel attitudes, skills and knowledge, and of educational curricula for the training of
health professionals. Further, it requires attention to motivational and carreer development
aspects of health professionals, especially those working in remote rural areas.
Orientation of health care towards local needs and priorities presupposes what Macdonald
(1993) calls a 'health view' instead of a 'medical view' oriented to delivery of medical
services. Attention to the socioeconomic and cultural environment and 'wider circles of
disease causality' (Macdonald, 1993) should prevail over individual-oriented curative
approaches common to most delivery systems (with, of course, the same consequences for
health curricula as mentioned above).
The emphasis on intersectoral cooperation presupposes a 'health view' among the
representatives of relevant government agencies at all levels. Health is no longer the
product of vertical, top-down (curative and preventive) health interventions by one agency
(the Ministry of Health), but of health-promoting horizontal 'linkages' between all
government agencies relevant to public health (public works, agriculture, housing,
education etc.) in the framework of an 'integrated' approach.2)
1.3.
Between Alma Ata and the year 2000
In the past fifteen years, the Alma Ata policy statements and the objective of 'health for
all' have proved to be far too ambitious and sometimes even naively idealistic. Most
important, there was an enormous gap between formal policy goals formulated
internationally or nationally on one hand, and the reality of their (national or local)
implementation on the other. Many governments have formally accepted the recommenda
tions of the Alma Ata declaration (there were 134 signatories of the declaration).
However, in practice this often came down to a selective use of them that best suited
national political or economic interests, the need for short-term successes, or the
preference for a continued allocation of scarce resources to curative, intervention-oriented
medicine.
But this should not blind us to the positive effects of Alma Ata. The declaration gave
impetus to a radically new perspective on health, disease, and the relationship between
health care and development in general. It stimulated the process of reorientation of scarce
resources and facilities from curative, urban, hospital-based and vertically organized
monosectoral health care for the happy few to promotive and preventive, rural, local
health-centre-oriented, participative and multisectoral health care for the majority of the
(rural and urban) poor. Many countries started reviewing their health systems and adapting
their national policies and strategies in accordance with the PHC strategy, supported by
8
donor countries and organizations, and non-governmental organizations. This was
increasingly reflected in plans of action in which the basic elements of the PHC strategy
(see 1.2.) can easily be recognized. Some governments have recognized that health care
facilities should be attuned to the needs of the majority of people rather than to those of
the small, well-to-do minority with purchasing power.
In these countries priorities changed accordingly. More resources were allocated to basic
health services (promotive, preventive and curative). Curricula for health professionals
were adapted to the new role allocated to health workers in the PHC concept. Attention
was paid to the necessary changes in attitude of health professionals towards illiterate,
poor villagers and their participation in community-based health programmes. Greater
respect was demanded from scientists and health professionals for locally available
knowledge and local solutions to health problems.
The objectives of comprehensive, community-based PHC are, almost by definition, long
term objectives with little short-term results to boast of. On the other hand, expectations
of the short-term impact of PHC have often been unrealistically high. Though not stated
so clearly in the declaration, the message of Alma Ata is a political one. Its
implementation implies struggle with power and interest groups at the local, regional and
national levels of administration and with professional interest groups. It further
necessitates a radical reorientation of health services, management (especially of district
health systems), financing and cost recovery, development of PHC-oriented curricula for
health professionals and training materials for VHW's, professional attitudes towards target
groups of health programmes, VHW's and local knowledge and practices, research etc. It
will be evident that such a reorientation is also a long-term process.
In its report of the second evaluation of the 'health for all' strategy, WHO (1993a) signals
some positive trends. The majority of countries formally endorse 'health for all' as a policy
objective. In many countries there is also a growing attention to the issue of equity in
health. Further this political commitment is reflected in national patterns of allocation and
distribution of resources for PHC.3) A positive trend can also be discerned, especially in
Asia, in leadership development (WHO, 1993a; 40-46).
In the report some positive global trends with respect to the reorganization of health
systems towards PHC are mentioned. First, many countries are in a process of
reorientation towards PHC, and away from (exclusively) curative-oriented second- and
third level health care. Second, in many countries there is a growing awareness of the
importance of more efficient use of resources and of the need to improve access to and
quality of health facilities. Third, in many countries in the Far East and the Pacific there is
a clear emphasis on the comprehensive character of PHC, all eight elements of which
should be represented in local programmes. Issues of special attention are decentralization,
integration, district health systems, and health services in rural areas. Fourth, a growing
number of countries adopt policies of decentralization in order to improve the use of
resources for PHC. Some countries give special attention to the decentralization of
authority and responsibility to the district level (WHO, 1993a; 47).
However, the overall conclusion by WHO is not encouraging: 'Some major programmes
based on the primary health care approach have proved successful. In general, however,
9
disparities and inequalities in availability of national health services have remained high
and have even increased in some cases. This is partly due to the fact that an intensified
effort in one programme has been accompanied by a decrease in another.' (WHO 1993a;
48).
The main reasons for this continuation, or even increase of disparities, given by WHO are:
the continued provision to some population groups of unnecessary, expensive and
sophisticated health services, reducing the availability of resources for the rest of
the population;
the slow progress from a vertical to an integrated approach;
the influence of pressure groups advocating ’glamorous' expensive second- and
third-level care, supported by curative-oriented parts of the health profession;
national economic difficulties:
the slow expansion of services to underserved areas;
the lack of trained and motivated staff;
the lack of supervision;
referral problems (WHO, 1993a; 48-49).
With reference to health care coverage, the WHO report shows that since 1985 the
percentage of people covered with essential services has increased worldwide. Examples
are coverage with safe water supply and sanitation, and different components of mother
and child care (especially immunization; in 1990 the average global immunization rate
against measles, diphteria, pertussis, tetanus, poliomyelitis, and tuberculosis was 80%)
(WHO, 1993a). Improvements in coverage (but also in other determinants of health like
nutrition, education etc.) are reflected in improvements in health status indicators like
infant mortality rate, life expectancy at birth, and birthweight status.
At the same time it should be stressed that in many countries the total number of people
without access to basic health care, safe water, sanitation and other services is increasing.
Further, the gap between the developed (and many developing) countries and the least
developed countries has widened, as have the gaps between groups within countries
(between urban and rural areas, pockets of extreme poverty in urban areas, marginalized
groups based on ethnicity etc.).
Data on coverage with many other elements of local health care are hard to interpret
because most countries do not provide further specifications (WHO, 1993a).4) Another
limitation of data on coverage provided to WHO by the member countries is the fact that,
while data on coverage by some separate (sub)elements are provided, data on coverage by
all (sub)elements of primary health care is not available (WHO, 1993; 142).
Right from its acceptance as a global strategy, PHC has been controversial. One of the
main themes has been the debate about selective versus comprehensive, and vertical versus
horizontal PHC (Van der Geest et al., 1990; Macdonald, 1993; Rohde et al., 1993). As has
been said before, many countries have selectively implemented the strategy of PHC. Such
lip-service paid to the Alma-Ata declaration is widely acknowledged to be a threat to the
10
most crucial elements of the PHC-model and the long-term survival of the model itself
(Tarimo and Creese, 1990; Macdonald, 1993; Walt and Rifkin, 1990). Selective primary
health care hardly differs from 'traditional' outreach programmes and delivery-oriented
extension of health services through vertical health agencies.5)
Economic trends in the eighties and ninetees have in many respects been unfavourable for
the national health policies of developing countries and the attention paid by governments
to primary health care. Many developing countries were hit by economic stagnation, and
involved in programmes for structural adjustment and economic stabilization. Under the
influence of economic recession, structural adjustment and privatization, international
donors and governments of developing countries have tended to resort to the implementa
tion of vertical, target-oriented programmes for specific health problems: family planning,
immunization, nutrition, vitamin A, ORT etc. Critics of this approach stress that such
programmes tend to produce short-term results which give the illusion of progress, but
have a limited sustainability.
Related to this is the assertion that certain forms of selective implementation of PHC may
produce second rate health care. The policy goals of 'community participation', 'selfreliance' and 'self-help' may be misused by governments to evade their responsibilities by
having carried out health care tasks in an inexpensive way by superficially trained lay
persons. Thus, cutbacks in health care expenditures by the government may be presented
as a radical reorientation and improvement of the quality of the health care system
(Tarimo and Creese, 1990; Van der Geest et al, 1990).
Under the influence of the ideology of self-help and self-sufficiency, the strategy of PHC
has long been too much focused on the role of community-based health care and the
Village Health Worker (VHW), isolated from the larger administrative structures they are
part of. Little attention was paid to linkages with basic health services provided by the
government, to the detriment of referral, support, guidance, training, logistics etc. for the
local level (Streefland and Chabot, 1990).
Another policy objective af Alma Ata is 'intersectoral cooperation'. In practice, realization
of this objective of PHC has proved to be very difficult (as it has been in 'integrated
development' in general). All too often relationships between government agencies are
competitive rather than complementary or mutually supportive. Segmentation and
fragmentation tend to prevail over cooperation. Sectoral bureaucratic biases against
cooperation, a narrow conception of health as the responsibility of medical services, and
isolated health planning create separate hierarchies rather than comprehensive programmes
(WHO, 1993a; Macdonald, 1993).
Macdonald (1993) warns against such forms of forms of non-cooperation between sectors,
and even within sectors. With reference to the health sector, the author gives the following
examples of detrimental forms of intra-sectoral segmentation:
between public health (promotive/preventive) and curative care;
between health education and specific interventions (mother and child care,
immunization etc.)
11
Finally, PHC is increasingly being criticized from a sociological point of view.
Mechanistic ’systems’ thinking has dominated (and still does so) the analysis of
sociological aspects of PHC and of policy processes. Relationships between actors at the
local level ('the community'), or between actors at the local, intermediate, national, and
international levels are generally presented as relatively unproblematic and manageable
through well-defined (national) policies. Thus, the practice of PHC has been too much
influenced by the necessarily rather simplistic policy language of the Declaration of Alma
Ata. Glimpses at the problematic nature of policy implementation are few and far
between: 'Public health action may be confined to the national level and therefore limited
in scope' (WHO, 1993; 139).
An example (with important policy consequences) is the concept of 'community'. Views of
the 'community' in terms of commonality of interests, at the cost of attention for processes
of segmentation and differentiation, are often based on political ideals and ideological
premises, but seldom on sound social research. Development donors, government agencies
and NGO's alike subscribe to such generalizations, though each for their own reasons (an
unproblematic view on 'reaching the target group'; nationalist rhetoric and playing down
socioeconomic differences; ideological assumptions about 'traditional' village society).
Streefland and Chabot rightly stress that there is a need to turn away from such 'common
assumptions about the fundamental unity of village society' (1990; 34).
Especially where the issues of community participation, self-help, etc. are at stake, this
seems to be crucial. Many interventions are based either on the assumptions of unity and
commonality of interests at the local level, or on a class model and economic classes as
groups with commmon interests. Thus, other important (and often multiple, shifting and
conflicting) loyalties may be lost sight of: kin group, ethno-religious, patron-client etc.
And the 'target groups' may in reality have other 'real' needs and priorities than those
ascribed to them by donors, governments and NGO's.
1.4.
Challenges for the future
From a world economic point of view, the future for developing countries, and especially
for the poorest among them and the poorest groups and regions within them, is not bright.
At the same time, the populations of developing countries will continue to increase. When
seen from the perspective of health care, future population growth will in many countries
undo increases in coverage by health services. Even though the percentage of people
covered by health services may increase, the absolute number without access to basic
health care may well continue to rise (WHO, 1993a).
Especially under conditions of economic recession and structural adjustment (cuts in
government spending, privatization, deregulation etc.), 'non-productive' sectors like
education and health run the risk of being curtailed first. With national governments
escaping from their responsibility to deliver basic health services with a high coverage,
PHC may well become 'second-rate' health care for the poorest groups in society.
Thus, future challenges for PHC in developing countries are many. The continued lack of
access to basic health care by the majority of rural populations and a rapidly increasing
12
number of urban poor and marginalized groups in developing countries necessitate a
continuing process of reorientation of health expenditures from urban middle and upper
class, high-tech and curative towards promotive, preventive, and basic curative services
for the rural and urban poor, and other marginalized and special risk groups. Such
reorientations of health care have in the past experienced much opposition from interest
groups which form a strong political lobby for a curative, treatment-oriented system of
health care and its related status, and will continue to do so.
Many other challenges can be identified, like sustainability of improvements in health
status, AIDS, motivational and carreer aspects, health information systems, attitudinal
changes among health professionals etc. Without attempting to be exhaustive, the
following major future challenges will be treated below: district health care, urban health
care, gender aspects of health care, intersectoral cooperation and NGO's, and future
allocation of health resources.
A. District health care
A main theme in health policy in general, and PHC in particular, is decentralization of
authority and responsibility to the district level of administration.^ The district health
system has become increasingly important as ’a more or less self-contained segment of the
national health system' (WHO, 1988a), for the organization and provision of primary
health care. This intermediate level (in between the 'first contact' local village level and
provincial, federal state or national level) is supposed to play a key supportive role in
(future) PHC efforts (WHO, 1988a; WHO, 1993a). At this level higher skilled and more
specialized forms of care are available; treatment of more serious diseases takes place
here. Though rightly priority is given to PHC and the 'first level', it should be stressed that
the weakness of second- and third level care may have serious consequences for the
effectiveness of health care as a whole (WHO, 1993a; 63). Therefore, specific attention
will be needed for strengthening the role of the hospital and institutional care in the
concept of PHC.
The district can provide logistical support and highly trained staff for the training of
trainers and village health workers. However, in most countries capabilities for planning,
implementation, management and support are weak. Therefore, special attention will be
needed for the following 'pillars' of the district health system:
1.
2.
3.
4.
5.
organization, planning and management;
financing and resource allocation;
intersectoral action;
community involvement;
development of human resources (WHO, 1988a).
Important preconditions for the effective functioning of district health systems:
the full commitment and support from the national level;
some degree of autonomy and authority in planning; management, decision-making
and resource allocation;
13
♦
an overall national plan for PHC, in which policies and broad strategies are defined
(WHO, 1988a).
At district level, special attention will have to be paid at the development of strategies for
cost-recovery and the mobilization of local resources. However, in the context of
privatization and structural adjustment, special care will have to be taken that ideologies of
self-help and mechanisms for cost-recovery do not degenerate into new forms of exploi
tation of poor and marginalized groups.
B. Urban health care
Another major challenge is the struggle against the negative welfare and health effects of
rapid urbanization in developing countries. In 1990, 37% of the population of developing
countries (1.500 million people) lived in urban areas. In these countries, the urban growth
rate during the period 1985-1990 was 4,5% . The high pace of urbanization of the last
decades is expected to continue in the decades to come. By the year 2000, there will be
eighteen mega-cities (cities with 10 million or more inhabitants). By the year 2025 total
urban population will increase to 4.000 million or 61% of the total population (WHO,
1993a). The number of mega-cities will also increase considerably during this period.
In many developing countries the pace of urbanization is not matched by the expansion of
health care and other facilities. Main victims are, of course, poor and marginalized groups
without or with low-paid employment, a low educational level, and little or no access to
facilities. The gloomy picture of poor housing, delapidated infrastructure, lack of safe
water supply and sanitation, of facilities for basic health care and education, and the high
rates of morbidity and mortality associated with it looms large. Major health hazards are
malnutrition, water-borne diseases, diseases of the respiratory tract, stress, diseases causes
by environmental degradation, sexually transmittable diseases (AIDS), drug and alcohol
addiction, and injuries caused by violence (WHO, 1993a). The specific characteristics
associated with the urban enivironment (its rapidly changing demographic and
socioeconomic context) require special approaches to urban health care, based on the
district health care model (WHO, 1993b)
C. Gender aspects of health care
Health services have a long tradition of focusing on women and children, especially in
MCH programmes. For a long time, however, women have in this context been mainly
perceived as passive beneficiaries and as mothers of their children, rather than as women
in their own right, with their own needs, ideas and priorities. It was only in 1985 that the
question was formulated 'Where is the M in MCH?', and in 1987, subsequently, that the
Safe Motherhood Initiative was launched by the WHO, highlighting the tragedy of
continuing high maternal mortality rates in many parts of the world, and indicating an
even higher maternal morbidity. Since then, increasing attention has been given to these
problems and their underlying causes, which undoubtedly will remain a major challenge in
the near future.
14
In the meantime, in 'Women in Development' (WID) circles, the debate was intensified on
how to increase access to and control over resources for women, how to support their
empowerment and their strife for autonomy in different spheres of their lives. These issues
have been relatively neglected in the context of PHC, in spite of its longstanding rhetoric
on such concepts as equity and community participation. As mentioned before, however,
the uncritical and too general use of these concepts has for too long left many inequities
and differences within communities, including gender differentials, unspecified and
unattended. Similarly, 'women' as a category can no longer be simply approached as a
homogeneous group, ignoring the huge differences that can exist between women within a
community (e.g. between married and unmarried women, between women with some
education and those uneducated, between upper class and poor women)
In fact only recently, with the shift in emphasis from 'Women in Development' to 'Gender
and Development', an increasing interest in gender issues in the context of PHC pro
grammes is noticeable, as apparent, for example, from a mushrooming of workshops to
sensitize health personnel in these matters. The former exclusive focus on women is
replaced by an emphasis on gender relations and their influence on patterns of decision
making, on differential access to resources, and on different health benefits, with special
attention for disadvantaged groups. A translation of these new conceptualizations into daily
health practice, or, in other words, the operationalization of gender in PHC programmes, is
one of the big challenges of the 1990s.
A major effort will be needed to balance gender inequities in access to and control over
resources including health services. More concrete steps in actual PHC programmes are to
involve women as active participants in decision-making in all matters concerning their
health, be it in health committees, as individuals, or in informal groups; and, on the other
hand, to ensure male involvement in programmes traditionally geared mainly towards
women but in fact concerning both equally, like family planning. Changes in the
underlying power relations form part of the long-term challenges in development.
D. Intersectoral cooperation and NGO's
As has been argued above, mutual relations between government agencies (sectors), and
relations between government agencies and NGO's are often competitive and segmentary
rather than mutually supportive and complementary. In the near future, intersectoral
competition for resources may even increase in the context of economic readjustment, cuts
on government spending etc. (Walt and Rifkin, 1990). Further, under conditions of a
central government backing out of its responsibilities and cutting its spending on (social)
programmes, while new competitors from the NGO-world fill the gap with increasing
foreign donor support, cooperation between government agencies and NGO's may well
become part of the problem rather than of the solution.
1
There is even the danger of health NGO's involved in the implementation of PHC
programmes bearing the burden of what are in fact government responsibilities. In this
respect a distinction is often made between parallel development activities by NGO's on
one hand, and complementary activities on the other. But there is a third possibility:
NGO's taking over responsibilities from a state incapable or unwilling to fulfill its
15
obligations towards its population. Often, it should be added, to the detriment of the
NGO's concerned. They are usually unable to do on a large scale what government
agencies have failed to do, lose their credibility with the population, their flexible and
innovating approaches, and the motivation of their personnel.
E. Future allocation of health resources
The increase of 'lifestyle diseases' (chronic noncommunicable diseases, often associated
with Western consumption patterns) like cancer, heart disease, hypertension etc. among the
growing middle and upper classes of many developing countries poses a serious threat to
the long-term availability of adequate public resources for PHC. Rohde et al. (1993) stress
the importance of continued allocation of public resources to 'pre-health transition society'
(the young population in general, with special attention to the control of infectious
diseases and malnutrition). In a global context of economic liberalization and privatization,
it is of the greatest importance that in the decades to come the private (non-voluntary,
profit) sector caters to the needs of the well-to-do, while public resources and non
governmental (non-profit) resources continue to flow (and increasingly flow) to poor and
marginalized groups of society. Within allocations to the health sector, priority should be
given to prevention of further budget cuts for PHC, to finding new sources for funding
and ways to use them more efficiently end effectively (Rohde, et al., 1993; Tarimo and
Creese, 1990)
However, there may be some complications here. First, it is the middle and upper classes,
and not the poor, that can exert an effective demand on the health care market in
developing countries. Second, these (urban-based) classes have access to political
decision-making processes, and thus can influence the allocation of resources. Moreover,
for governments with urban-based political clientele PHC is not a crucial issue. In such
cases, short-term results and prestige may have priority over high-quality PHC (Van der
Geest et al., 1990).
As a 'countervailing power' in developing countries, the role of national NGO's with a
policy influencing and lobbying function towards their governments, and at the same time
a critical view on government health expenditures, may well be of crucial importance in
the future. In this respect, the following reservation made by WHO (1993a) seems
necessary: 'Although voluntary organizations are nationally organized in a number of
countries, the lack of a policy framework for coordinating their efforts remains a
significant obstacle to the full utilization of their skills and resources' (WHO, 1993; 78).
I
16
2.
2.1.
INDIA: A GENERAL COUNTRY PROFILE
General characteristics
India, with a land surface of 3.288.000km2 (approximately 100 x the area of the
Netherlands) and a population of about 850 million people (1991), is demographically the
second largest country in the world after China. During the 1981-1991 period average
population growth was 2,1% per year. According to the 1991 census, during this period
the population of India has increased by 23,5% (1971-1981: 24,6%).7)
India is characterized by an enormous sociocultural, ethnic, linguistic, religious and
ecological diversity, which makes generalizing about the country difficult, if not impossi
ble.^ The large majority of the population are Hindus (83%, most of which live in the
Gangetic plain and central states). Other important religious groups are Muslims (11%),
Christians (3%), Sikhs (2%), Buddhists (1%) and other minorities (Parsees, Jains, and
others). The Christian minority is for the greater part concentrated in the southern states of
Andhra Pradesh, Goa, Karnataka, Kerala and Tamil Nadu, and in some northeastern states
(Nagaland, Meghalaya).
The majority of India's population (75%) lives in rural areas. Most of them are small
farmers, landless, and agricultural labourers. It is estimated that between 37% and 46% of
the rural population has no access to land, and fully depends on (irregular) wage labour
for its daily subsistence. Their weak socioeconomic position makes the poor sections of
India's rural populations very vulnerable to unfavourable external economic influences like
price increases. Such economic developments and other calamities (e.g. disease) may
easily set off a process of growing indebtedness to moneylenders and loss of means of
production (land), often leading to 'bonded' forms of labour.
In 1991, 217 million people (25%) lived in India's cities. Urban population increases at a
considerably higher rate (3,9% per year) than rural population (1,8% per year). Decadal
growth of India's urban population in the period 1981-1991 was 36,19% (VHAI, 1991).
India now has more than twenty cities with a population over one million. Urban
population growth is increasingly becoming an autonomous process, no longer caused
primarily by rural-urban migration patterns. The largest cities of India and their (1991)
populations are: Bombay (12,6 million), Calcutta (10,9 million), Delhi (8,4 million),
Madras (5,4 million), Hyderabad (4,3 million), and Bangalore (4,1 million).
India gained its independence from Britain in 1947. After decolonization it became a
federal state based on secularism and parliamentary democracy. It comprises 25 federal
states and 7 union territories. Principles of national policy, including the relationship
between the state and national levels, are laid down in the constitution. While key issues
like foreign affairs and defence are national responsibilities, agriculture, health, education,
and other sectors are under state responsibility. Apart from national and state responsibili
ties, there are the joint responsibilities of the 'concurrent list' (DGIS, 1994). If national and
state interest are in conflict, final decisions are taken at the national level. The latter is
clearly the stronger party, as is also shown by the fact that president's rule can be
proclaimed if political turmoil at state level is supposed to threaten national stability.
17
The state is administratively divided in the district, block (taluk), and village levels. In
1993, this system of decentralized local government (the 'Panchayat Raj' system) has been
revived by the central government, possiby with important consequences for
developmental efforts at the local levels of administration.
State
Size (km2)
Madhya Pradesh
Rajasthan
Maharashtra
Uttar Pradesh
Andhra Pradesh
Guj arat
443.446
342.239
307.713
294.411
275.045
196.024
Population (million)
66
44
79
138
66
41
The five largest states according to size (source: DGIS, 1994)
State
Size (km2)
Uttar Pradesh
Bihar
Maharashtra
West Bengal
Andhra Pradesh
Madhya Pradesh
294.411
173.877
307.713
88.752
275.045
443.446
Population (million)
138
86
79
68
66
66
The six largest states according to population (source: DGIS,
1994)
The constitution also addressed deep-rooted aspects of social and religious life and
tradition, like the caste system. In the Indian constitution (1950) the caste system was
formally abolished, caste distinctions no longer recognized and discrimination of lower
caste members or 'untouchables' (harijans, dalits) offically forbidden. Since then,
distinctions between the major caste divisions (Brahmans or priests; Kshatriyas or
warriors; Vaishas or merchants/big landowners; Sudras or craftsmen/labourers) have lost
part of their significance.
However, especially in rural areas hierarchical social divisions of jati, endogamous kin
groups based on (sub)caste divisions, remain a major determinant of Indian social life.
Other determinants of (urban and rural) social life that even seem to have gained in
importance during the last few years are religious and communal affiliations. In the
practice of development interventions such 'traditional' loyalties, hierarchical patron-client
relationships and forms of socioeconomic dependency (bonded labour) may be stronger
than the unity and solidarity of 'community' or 'class'. An important aspect of Indian
political life is the politicization of these bonds of identification, loyalty, and dependence
down to village level under the influence of universal suffrage.
18
2.2.
Recent political developments
India is known as 'the largest democracy in the world', and rightly so. The country has a
strong tradition of parliamentary democracy and elected governments at the state and
national levels, which is virtually non-existent in other Asian countries. It has a multi
party system, and general elections with voting rights for men and women. Moreover,
India's parliamentary democracy is built upon a society that in its long history has become
used to incorporating and tolerating a great variety of sociocultural and religious elements
within its boundaries.
However, since the seventies severe threats to the democratic character of the national
state have come up. In the 1975-1977 period unconstitutional rule by prime minister
Indira Gandhi brought the country to the brink of civil war. At the same time, Indian
democracy showed its teeth by bringing to an end a period of uninterrupted rule by
Nehru's and Indira Gandhi's Congress Party: in the period between 1977 and 1980 the
Janata Party was in power. However, in 1980 the old order was restored, with the
Congress Party in power again through what seemed to have become a kind of hereditary
rule instead of parliamentary democracy. During the past years, Indian political life was
characterized by rather unstable coalition governments without absolute majority. Since
1991, the Congress Party has again become the largest party without, however, being able
to gain an absolute majority in parliament.
It was also in the eighties that other political threats to India's national unity gained in
momentum. First, communalism and separatist movements have become severe threats to
the long-term national unity and stability of India. These problems have manifested
themselves most clearly in Kashmir (Islamic separatism seeking to join politically with
Pakistan or to become fully independent), Punjab (Sikhs striving for an independent
Khalistan state), the Assamese separatist movement and other (separatist) political turmoil
in India's northeastern states.
Further, in recent years religious cleavages have posed a new threat to the Indian state
(and especially to its secular character, guaranteeing an equal position to members of all
religious groups). The growth of radical Hindu fundamentalist and nationalist movements
and political parties (in particular BJP), the Ayodhya affair and many other conflicts and
incidents have seriously strained relations between (fundamentalist) Hindus on one hand,
and Muslims and other religious minorities on the other.
The political tensions mentioned above have also negatively affected the human rights
situation in India. Through a number of legal instruments, the national government has
given itself greater powers for intervention in state politics considered to be dangerous to
the national stability. 'President's rule' has been decreed for the states of Punjab, Assam,
Kashmir and Tamil Nadu, often with negative consequences for the treatment of
individuals. Violations of human rights seem to occur on a large scale, a.o. in Bihar, Uttar
Pradesh and Andhra Pradesh. Some states seem to balance on the brink of a complete
social breakdown.9) While the human rights situation continues to be monitored by a
number of human rights organizations, political activists and the media, human rights
issues cannot be openly discussed with the national governments.
19
2.3.
Economic development
Economically, India is a Janus-faced country. On the one hand it has become an
important industrial and technological power, catering to the majority of its own needs of
consumer and capital goods. During the last decades it has experienced high industrial and
agricultural growth rates. India now has a middle class population of more than 150
million. On the other hand India is still among the countries with the largest number of
poor and illiterate inhabitants in the world.
In the eighties, India has experienced a period of rather strong economic growth, as shown
by aggregate macro-economic indicators such as GNP and industrial production. Average
growth of the GNP in the period 1980-1990 was 5,3% . At the same time, from GNP per
capita (USS 330 in 1990; World Development Report 1993) it will be clear that India still
belongs to the group of low income countries. There is increasing evidence that economic
growth of the last decades has mainly benefited the middle and higher classes, but at the
same time contributed to the further deepening of the gap between the rich and the poor.
Beginning with the rule of India’s first prime minister Nehru, central state planning has
played an important role in the Indian economy. The role of the central state in industrial
development and production was considered crucial for the long-term development of the
country. The main instrument of (economic) planning were the Five-Year Plan plans.10)
Emphasis was placed on heavy industry, mining and infrastructure. Main characteristics of
this period of considerable state intervention are the (industrial) strategy of import
substitution and the (agricultural) strategy of food production through ’green revolution'
technology. However, protectionism, high production costs and a low quality of production
were the other side of the coin.
From the seventees, and especially in the eighties, India has implemented a great diversity
of programmes for poverty alleviation (PAP's), like rural (self) employment schemes,
income generating programmes, wage employment programmes, backward area
programmes, training programmes and integrated rural development programmes (Shah,
1991). But, generally speaking, in its industrial and agricultural policies, India has been
betting on the strong, and direct alleviation of poverty has never had a clear priority.
According to the 1989 World Bank report, 40% (some 350 million people) of the
population is estimated to live under the poverty line, set for the period 1985-1990 at
about US$ 460. While during the last three decades the percentage of people living below
the poverty line has declined, absolute numbers have increased.n)
By the end of the eighties, India entered a period of economic recession, culminating in
the severe economic crisis of 1990-1991. With towering deficits and declining reserves,
India became increasingly dependent on foreign aid and the conditions on which such aid
is usually provided by bilateral and multilateral donors. In the eighties, during the rule of
Rajiv Gandhi (who was assasinated in 1991) a beginning had been made with the
restructuring and liberalization of India's economic policy. However, under the Rao
government, a radical programme of structural adjustment and economic stabilization was
introduced in 1991. India's economic reforms were supported by the World Bank, IMF and
bilateral donor countries. As a result of the introduction of this 'New Economic Policy'
(main features of which are deregulation, stimulation of foreign investment, privatization,
20
reduction or abolition of subsidies like those on fertilizer), international confidence in the
Indian economy was restored.
As in most developing countries, the programme for structural adjustment has set off
discussions about its consequences for the poor and marginalized sections of society.
Especially during the last few years there is a clear trend towards widening of the gap
between the rich and the poor. Poor and marginalized groups are to an increasing extent
excluded from the general process of development: rural small farmers and the landless,
small fishermen, urban poor and slum dwellers, the population of regional pockets of
poverty, especially in areas with a majority population of scheduled castes and tribal
groups, and women.
Poverty is regionally concentrated in Central and East India, where more than 400 million
people live. In particular the states of Uttar Pradesh, Madhya Pradesh, Orissa, WestBengal and Bihar show a gloomy picture: a stagnated agricultural sector, low incomes,
unemployment, malnutrition and poverty diseases, a lack of adequate facilities for basic
health care and education in a context of high population growth and a lack of resources
for development. The position of marginalized groups (esp. scheduled castes and tribes;
see below) is even worse. Poor and marginalized groups have to do without basic social
services, amenities, and social rights. Thus, these groups lack access to basic health care,
education, housing, safe water and sanitary facilities. Unemployment or unfavourable and
unhealthy working conditions further complicate their position. Forms of bonded labour
exist in a number of states, child labour is a widespread phenomenon.
2.4.
Some areas of priority
In this part some priority themes will be highlighted: the position of women, urbanization
and the urban poor, and scheduled tribes and castes. Within the scope of this desk study a
choice has been made, so that many other important themes, as for instance environmental
degradation and displacement of rural populations for large-scale infrastructural projects
have been left out.
A. The position of women
Notwithstanding the full recognition of the equal rights of women in the Indian
constitution, the reality of the position of women in the generally patriarchal Indian
society is different. In a sociocultural and economic sense, women in many parts of India
have a position inferior to that of men. They often lead a socially isolated life, are
illiterate, and lack access to basic human needs and facilities. This is clearly reflected in
important social and health indicators like female literacy rate, maternal mortality rate,
malnutrition of female infants etc (see chapter 3).
From an economic point of view, women are generally worse off than men. Apart from
their household tasks, women bear the greatest burden of agricultural labour, and play a
very important part in the (urban) informal sector. If women perform wage labour, usually
they get a lower payment than men for the same work. In case of restructuring of
21
i.
economic activities, as for instance mechanization in agriculture, women are generally the
first to be hit and lose their access to important sources of income.
The general preference for male children in combination with the use of modern medical
technology to determine the sex of the foetus have led to a mushrooming of the practice
of female foeticide through abortion.12) Though in July of this year a law forbidding the
use of sex determination tests for this purpose has been passed in the Lokh Sabha
(parliament), this practice is hard to control. For the poorest sections of society, the
(cheap) alternative is female infanticide shortly after birth.
Indebtedness of the relatives of the bride at best, but in the worst case mutilation or
murder of the woman as a result of conflicts related to the payment of dowry further add
to the social and physical burden carried by women. According to recent estimations, the
total number of ’dowry deaths' in the state of Uttar Pradesh alone in 1993 amounted to at
least 1952 women. Such practices cannot simply be considered ’traditional’, but rather
seem to be related to an increasing desire for modern consumption goods.
B. Urbanization and the urban poor
Problems related to excessive urban population growth are many. According to recent
estimates, between 28% and 40% of the urban population live in conditions of absolute
poverty. The number of slum dwellers was estimated at 50 million in 1981; estimations
for the year 2000, when a third of the population (350 million people) will live in urban
areas, are that India's cities will have 80-100 million slum dwellers. A group which is
even more marginalized are the street dwellers.
Key problems in urban areas are unemployment, low wages, the lack of (low cost)
housing, clean drinking water, sanitary facilities, waste disposal and other facilities and
services, such as education and basic health care. The most common diseases are those
diseases associated with poverty, malnutrition and unhygienic living conditions such as
hepatitis, malaria, tuberculosis, worm infections, and diarrhoeal diseases.
The recent outbreak of the (lung) plague in the city of Surat (Gujarat) clearly shows what
might become the scenario for many other urban agglomerations throughout India under
conditions of high urban population growth (in the case of Surat clearly related to
migration of low paid labourers), a provision of services lagging far behind the rate of
urban growth (and, more important, neglecting the poorest sections of urban society), and
a complete lack of access to basic facilities for a large group of urban poor (Surat had a
1991 population of 1,5 million. With a decadal growth rate of 87,4% in 1971-1981, and
64,2% in 1981-1991 it is the fastest growing city of India; Bose, 1993).
C. Scheduled tribes and castes
In India there are many underprivileged groups (socially marginalized, economically
backward, or living in remote areas with little access to basic services for health,
education etc.). Examples are small fishers, hill people and the inhabitants of urban slums.
22
An important underprivileged group, formally recognized by the Indian Constitution, are
the so-called scheduled tribes. According to the 1981 census tribals {adivasi) comprise
more than 400 tribal groups with a total population of 51.628.638 (excluding Assam), or
7,76% of the 1981 population. Most tribal groups live in Central and Northeast India.
According to the 1981 census, Madhya Pradesh had the largest tribal population of all
states (11,98 million), while Mizoram had the largest proportion of scheduled tribes
relative to the whole (state) population (93,55%), followed by Nagaland (83,99%) (WHO,
1990). Members of scheduled tribes are often dependent on agriculture (shifting
cultivation) for their subsistence. Encroachment on their land for forestry, mining, large
infrastructural projects and other 'developmental' activities poses a severe threat to the
survival of these groups.
Another important underpriviliged group, formally recognized as such by the Indian
Constitution, comprises the 'scheduled castes'. Scheduled caste members still suffer all
kinds of socioeconomic (e.g. occupational) and political discrimination and
marginalization. Under presidential decree, some castes have been given the status of
scheduled castes under the Indian Constitution. The main criterion is extreme social,
educational and economic backwardness of a caste arising from 'untouchability' (WHO,
1990). Untouchables are generally known as harijans or dalits.
According to the 1981 census, 1.108 scheduled caste groups were discerned in India
(15,75% of the total population). The highest percentage of scheduled castes to the total
(state) population is found in Punjab (26,87%), followed by Himachal Pradesh (24,62%).
The main occupation of members of scheduled castes is agricultural labour. Many of them
are bonded labourers. Members of scheduled castes also perform a variety of heavy, lowincome and low-status labour (leather, scavenging), or specific crafts and occupations
depending on local/regional pratices: weaving, fishing, wood-, stone- and metalworkers.
In north India and parts of west India, Dai (traditional birth attendants) belong to the
scheduled casts (WHO, 1990).
Notwithstanding their formal recognition as marginalized groups needing special attention
for their specific problems, marginalization, discrimination and exploitation of scheduled
castes and tribes are widespread. State government attempts to increase socioeconomic and
political opportunities for lower caste members often meet with resistance from groups
with a higher caste background or, as recently happened in the case of Uttar Pradesh, from
the central government. The recent outbreaks of violence in Uttar Pradesh show that the
issue of lower caste access to government jobs still releases strong emotions. At the same
time it becomes clear that the caste issue has become secondary to national and state level
party politics.
The health status of schedules tribes and castes is very low. Many health hazards of these
groups are related to their poverty and nutritional status, sanitary conditions and relative
isolation. Poverty, malnutrition, a low literacy rate, absence of safe drinking water and of
health services are characteristic of their situation. Prevalent diseases among many tribal
groups are, among others, malaria, tuberculosis, influenza, dysentery, sexually
transmittable diseases, and addictions. The generally low health status of these groups is
reflected in indicators like morbidity and mortality (WHO, 1990).
23
2.5.
NGO’s in India
As a consequence of the - historically grown - relatively large degree of local autonomy
from the central state, India has a long tradition of local-level non-governmental
voluntary action.13) Local groups have since long organized themselves for various
socioeconomic activities on the basis of caste, religion, village and other identities. This is
reflected in the existence of millions of non-governmental local initiatives for various
purposes (Shah, 1991).
Shah estimates the total number of non-governmental development organizations
(NGDO's) among them at about 15.000 (Shah, 1991). Until quite recently most of these
NGO’s, which often had (and still have) a Gandhian or Christian background, resticted
their activities mainly to relief aid and charity, education and health care (hospitals). Since
the seventies, the NGO-'sector' has grown considerably, and in the field of NGO’s a
greater differentiation has become visible (which is also the result of NGO’s with a
Marxist or other ideological backgrounds entering the arena). New priorities became,
among others, target group organization and participative strategies, creating awareness
and local self-reliance of target groups, economically feasible and needs-oriented
development strategies (e.g. primary health care), scheduled tribes and castes, women,
environmental degradation and sustainable development, human rights and advocacy.
NGO’s should be registered under the Societies Act of the state in which they operate.
Once registered, NGO’s can generate their own funds from local, regional or national
private sources or receive government funding. In order to receive foreign donor funding,
NGO’s should possess a FCRA number (Foreign contributions Regulations Act of 1976).
Data about the geographical distribution and concentration of NGO’s are not univocal.
However, there is a strong presence of Indian NGO activity in the states of Tamil Nadu,
Andhra Pradesh, Kerala. Orissa and West Bengal. Relatively few NGO’s are found in
Bihar, Haryana, Madhya Pradesh, Punjab, Rajasthan and Uttar Pradesh (Shah, 1991). A
relatively high concentration of NGO-activity in the states of South India (which are not
the poorest states) is mainly caused by religious-historical factors: the Christian
background of many NGO’s and the concentration of .63% of India's Christian population
in the four southern states (Shah, 1991).14)
Shah distinguishes three types of NGO’s, on the basis of their approaches and ideological
positions:
the 'welfare' type: mainly oriented to service delivery (women, children, the
disabled, the poor; rehabilitation, income, education); absence of empowerment
strategies;
the 'development' type: oriented towards the provision of infrastructure, basic
amenities, health, education, production, income and local self-reliance; capitalist
or Gandhian ideology;
the 'empowerment' type: attention to political context, mobilization and
participation, conscientization and empowerment, structural change.
Shah concluded that most NGO’s follow the welfare and development approaches, and do
not relate poverty and exploitation with broader societal and political processes, even
24
though many of them claim to follow 'empowerment' strategies (1991; 12).15)
According to Shah, about 30% of Indian (developmental) NGO’s receive foreign donor
funding. Many of these NGO's are funded by more than one foreign donor. The total
number of foreign donor organizations amounts to more than 130, contributing an
estimated Rp. 7.000 million in 1990 (Shah, 1991).
In its seventh Five-Year Plan, the Indian government for the first time explicitly
recognized the necessity of involving NGO’s in implementing rural development and
poverty alleviation programmes of the government (Cebemo, 1989). On the positive side,
an increasing amount of government funds is channeled through NGO's, new forms of
government-NGO cooperation can develop, and doors are opened for NGO's to influence
government policy. On the negative side such recognition and cooperation may easily
degenerate into cooption, and restrict the room of manoeuvre for NGO's, reduce their
flexibility and capability to adapt to local circumstances, and undermine their useful
position as critical observers of government policy.
While the role NGO's play in the development process in India (and in general) should not
be over-estimated, contributions that NGO's can make to the development process are
many and thematically important. As actors in between the (national) state and civil
society they can play an important part in building a heterogeneous and democratic
society. For instance, by tackling problems and issues not taken up by the state and its
agencies (e.g. the environment, human rights, the position of women etc.); by taking an
innovative, creative and experimental approach and being committed; by standing up for
poor and marginalized groups in society (Cebemo, 1989; Shah, 1991).
but the dangers of organizational growth and professionalization associated with the
increasing availability of donor funds are clearly present:
bureaucratization and routinization;
the prevalence of vested (institutional) interests;
self-preservation;
the establishment of hierarchical NGO 'kingdoms' (depending too much on one
leader), and increasing competition in the NGO sector instead of cooperation and
coordination;
increasing awareness and instrumental use of donor conditions, fashions of the day
and 'policy speak';
increasing distance between NGO and target group; excessive preoccupation with
(upward) accountability towards the donor, at the cost of (downward)
accountability towards the 'target group';
loss of their innovative and flexible character; loss of distinction from 'traditional'
government delivery systems.
25
3.
3.1.
THE HEALTH SECTOR IN INDIA
Introduction
This chapter aims at providing a bird’s eye-view of the health and health care situation in
India, to help to contextualize the programme evaluation to the broader health care
realities in India. By its very nature and the inevitable constraint on size, the report
touches upon various topics, sectors and issues only briefly, highlighting some key
indicators or available data, wherever possible and relevant. While the focus is on the
Indian situation as a whole, an effort has been made to give some understanding of the
regional diversities and the emerging pluralities in the health situation as well as in the
responses by the central and state governments. An attempt has been made to draw
information from some key resource documents, both published and unpublished, which
pertain to data of the early 1990s so that the document presents a realistic view of the
current situation.
In the last few years the Government of India, after many years of a protected socialist
economy, has initiated steps towards a new economic policy to become integrated with an
open global market economy. This has led to an intense public debate on the whole issue
of privatization, structural adjustment and the inevitable effects on state investments in
welfare and health. A variety of political, social, cultural and economic factors have
played a very important role in the development of the country and have shaped the
strategies that evolved to organize health care services to meet the health needs of the
people. The same factors, especially the new economic policy will probably also be a
major determinant of strategies and responses in health care that are evolving in the 1990s.
India is a country of stark contrasts. On the one hand it is a rapidly industrializing country
that today can boast of a pool of locally trained scientific manpower among the top ten in
the world and with a recent experience of relatively successful 'green revolution'
(technological agricultural development) that made us self-sufficient in food. On the other
hand these technological successes have yet to affect the life of the large majority of our
rural population. This dichotomy means that we may reach the end of the decade with the
rather dubious distinction of also being among the countries with the large majority of the
poorest and the most illiterate citizens of the world. States like Kerala, Pondicherry, Goa
and some of the districts in other states have already reached or exceeded norms laid
down by the government as goals for the 'Health For All by the year 2000' strategy and
they compare well with some of the developed countries in the world. In contrast the
whole Gangetic belt, desert regions and northern-central region comprising Bihar, Madhya
Pradesh, Rajasthan, Uttar Pradesh and Orissa have health statuses and indicators far below
the national average and among the lowest in the world.
With one sixth of the world's population and nearly 2,4% of the world’s area, the regional
diversity and health status plurality of the country remain a great challenge to health care
policy makers and planners. The growing number of international (bilateral and
multilateral) collaborative efforts in partnership with the Indian government and the
voluntary sector also need to keep this in mind, so that their initiatives will help to
achieve acceptable health norms and standards by the year 2000, throughout the country.
26
3.2.
Recent political-administrative developments relevant to the health sector
The constitution has laid down directive priciples of state policy which cover the
relationship between the national government and the state governments, as well as local
self-government. The constitution brings Defence, Foreign Affairs under the Central List.
Health, Education and other sectors under the State List. Finally, some areas of national
life under a joint or concurrent list making it a collaborative responsibility of the centre
and states. In the health sector this covers areas such as drug manufacture and control,
pricing, medical education, prevention of food and drug adulteration.
The political and administrative structure therefore means that, while the central
government can sponsor and promote national health programmes, the organization and
delivery of health care services is primarily the responsibility of each state. Thus, while
there are prescribed national norms, there is also a great diversity in the actual situation in
the various states, availability and quality of health care services and programmes in the
country.
India has an ancient tradition of local self-government at the village level which explains
to some extent how the social systems have maintained such an unbroken continuity over
centuries. Legislations in the 1950s sought to strengthen these local institutions. State Acts
were passed, but in practice there were hardly any decentralized finances available to
them. In addition, the tradition of self-government was deeply affected by the caste
divisions of society and did not cater adequately for the participation of women and many
disadvantaged sections of traditional society. Local vested interest were well entrenched.
In 1993 constitutional amendments have been brought in by the government with two
major new features that are hoped to make the concept of local self-government and
decentralization an effective instrument of national development. Firstly, greater financial
and other powers and responsibilities have been devolved to the elected village bodies at
village, block and district levels. Secondly there is a 33% reservation for women and
reservations for scheduled castes and tribes (disadvantaged and marginalized sections of
Indian society) in proportion to their population. The eleventh schedule of the Act lays
down all the areas of development that will be under the purview of local village-based
elected bodies. These include public health, water and sanitation, and supervision of the
functioning of the Government primary health centres.
The implications of these new developments are yet to be fully realized by the government
health sector (the professionals and the bureaucracy) and even by the elected village
leaders, and the detailed modalities and strategies are still being worked upon. Some states
have initiated or completed the election process. Massive training and orientation
programmes are under way by the government and the voluntary (NGO) sector to equip
elected village (Panchayat') leaders to carry out their new responsibilities including those
related to health care. It is expected that the re-emergence of the concept and the new
commitment to 'Panchayat Raj' will be a crucial factor in the evolution of health care
strategies in the 1990s.
27
3.3.
Health and the voluntary sector
The 1980s was marked by the emergence of alternative trainers, networkers, researchers
and issue raisers in the voluntary sector. Moving away from the earlier role of alternative
service providers, many NGOs began to get involved with community organization and
empowerment. The 1990s is seeing a rapid professionalization of the voluntary sector and
perhaps the increasing emphasis on market economy values because of the increased
availability of funds. The 'alternative development dimension' is giving way to 'social
entrepreneurship' that may shift emphasis (like the profit/private sector), to those who can
afford rather than those who need!
After many years of relatively ignoring the voluntary sector, the 1982 National Health
Policy set a new trend. Not only was the voluntary sector recognized as a partner in
development, but, since the enunciation of policy, the Government has sought to direct
more of its funds to support projects run by this sector. Increased availability of funds and
resources and associated services while being a good indicator of the recognition of the
role of the voluntary sector, has also led to increasing concerns in the sector of, firstly,
cooption. Secondly, and perhaps more significantly, (in the context of the new economic
policy) there is the possibility of the government offloading its welfare responsibility onto
the voluntary sector. Some indications of this are directly evident.
There is a growing concern in India also about the use of the terminology 'NGO Sector'.
There is a feeling, that the 'for profit' private sector and the 'not for profit voluntary sector'
are two distinct sectors needing space, support and linkages, but that these should not be
clubbed together through the terminology of NGOs in government policy. Some groups
are convinced that this is a 'back door' measure to support privatization of welfare, educa
tion and health services, as part of structural adjustments.
3.4.
The population profile
The total population of India in the 1991 census was 846,3 million, with 74,3% of this
population based in rural areas and 25,7% of it in urban areas. This makes India the
second largest country in the world with an average annual exponential growth rate of
2,14% in the decade 1981-91. The latest data from the sample registration scheme shows
a natural increase rate of 1,90% in 1992.
The crude birth rate (CBR) was 29 and the crude death rate (CDR) was 10 in SRS 1992.
The decrease in CDR over the decades has been significant (in 1951 it was 27,4). The
CBR has also fallen significantly (in 1951 it was 39,9) but not fast enough to offset the
CDR and hence there has been a larger overall growth. India is currently in the third stage
of demographic transition.
The sex ratio has been a matter of concern. This indicator of women’s health status has
shown a worsening over the decades. In 1981 it was 934 while in 1991 it was 929
(females per 1.000 males). Males form 51,7% of the population and females 48% . The
percentage of the population belonging to schedule castes and tribes (marginalized and
underdeveloped sections of society) is around 24,6% .
28
The density of population (persons per km2) was 216 in 1981 and is now 267 in 1991. It
varies from 200 in the rural areas to 4.092 in the urban areas. Urban migration from
disadvantaged rural areas and inter-rural migration from disadvantaged to advantaged
areas is high. It is estimated that at the present urban growth rates 40 percent of the
population may become urban by the year 2000, putting a great stress on urban health and
welfare services.
The population distribution by age is a typical population pyramid, characteristic of
developing countries with nearly 40% under 14 years. The proportion of the elderly
population was 6,2% in 1981 and in 1991 it was 6,6% . Although the family structure is
still strong there are indications that care of the old is an emerging problem. The
sociocultural tradition has stressed universality of marriage and early marriage for women,
but the age at marriage has shown an increase over the years - and the increasing
opportunities for education and economic opportunity have contributed to this trend.
Life expectancy has shown improvement over the decades. For males from 41,9 years in
1951-60 it has reached 58,1 in 1986-91 while for females the rise has been from 40,6 to
59,1 in the same period. Here again the trends show a regional diversity. For the period
1976-80 Kerala showed a combined average of males and females at 65,5 while Uttar
Pradesh was down to 46,2 years.
The literacy rate for those over 7 years of age in the country has shown an increase from
43,7% in 1981 to 52,2 in 1991 (as a percentage of total population). Male literacy has
risen from 56,6 to 64,2 but female literacy is still rather low, the change being only from
29,8 to 39,2. Rural-urban literacy differentials are quite wide. In the 1991 census for
urban it was 73% , while for rural it was 44,5%. The male-female differential is even
greater. In urban areas it was 81,1% for males and 63,9% for females. In rural areas it
was 57,8% for males and 30,4% for females. The government has now initiated a literacy
programme aiming to tackle this major obstacle as a high priority matter.
The population of India is expected to cross the one billion mark by 2.000 AD as per
projections of expert committees. The implications of this trend on education, employment
and health services and opportunities are major and will remain the key challenge for the
decade.
3.5.
Health status and health problems
A. Some general data
In the previous section the changes in CBR, CDR and life expectancy gave an initial
overview of the health status of the Indian population. Now we will continue with a
number of other indicators of the health status and health problems of the population.
The Infant Mortality Rates went down from 129 in 1971 to 80 in 1991. While urban IMR
has decreased from 82 to 53, rural IMR has come down from 138 to 87 (which is still
fairly high). However, the regional differences are very large, with states like Kerala
29
having a rural IMR of 32 and states like Uttar Pradesh having a rural IMR of 152.
The under-five child mortality has shown a gradual decline from 21,2 (per 1.000 children)
in 1984 to 13.3 in 1988 and the goal for the year 2000 is to bring it down to 6,3.
Preventable deaths are being tackled by a massive programme of universal immunization,
control of diarrhoeal diseases and ARI's, and various types of nutritional supplementation.
However, much remains to be done.
In 1985 (Register General Newsletter - July 1987) the ten key diseases as main causes of
death were asthma and bronchitis (8,7%), TB (5,8%), pneumonia (5,7%), heart attacks
(5,2%), anaemia (3.5%), cancer (3.0%), gastroenteritis (2.5%), typhoid (1.9%), malaria
(1.9%) and dysentery (1.6%). This shows that along with the diseases of
underdevelopment due to poor nutrition, inadequate water supply and sanitation, the
diseases of development (cancer, heart disease) are also beginning to become significant,
putting a double burden on the evolving health services.
In 1981-85 (Register General Newsletter in 1987) the major causes of death in rural areas
were senility (22,4%), respiratory diseases (20,3%) including TB, infancy-related causes
(11,2%), fevers (9,5%), diseases of circulatory system (9,3%), digestive disorders (7,5%),
accidents and injuries (5,8%) and others (14%). Due to inadequacy of reporting and high
level of illiteracy, data on causes of death are not very reliable but some indications are
available of the types of problems from these statistics.
The maternal mortality rate is 500/100.000 births (UNICEF, 1983). This is still very high
and the statistics become significant when it is understood that more maternal deaths occur
in India in one week than in all of Europe in one year. The main causes in 1986 (Register
General Survey, 1987) was bleeding of pregnancy and puerperium (21,6%), anaemia
(17,0%), puerperium sepsis (13,1%), toxaemic (11,9%), abortion (8%), malposition of the
child (6,2%) and others not classifiable (22,2%). These indicate the continuing challenge
of providing trained birth attendants at the time of the delivery, nutritional
supplementation and basic ante-natal care which is already the focus of a major national
programme. However, the relative overemphasis on family planning aspects rather than on
maternal health and child health is a cause of continuing concern.
Malnutrition continues to be an important public health problem. Data from the National
Nutritional Monitoring Bureau have continued to show the extent of the problem, though
there are changes in qualitative trends. Prevalence of severe malnutrition among slum
dwellers and rural children is a major problem. The larger problem of mild to moderate
malnutrition affecting nearly 40% of the population has also to be kept in mind. Studies
by the Indian Council of Medical Research (1986) show that 7% of preschool children
have severe malnutrition, 47% moderate, 47% mild and only 7% are normal. A study by
National Institute of Nutrition (1980) shows that 65% of adult women, 75% of pregnant
women, 77% of preschool children and nearly 45% of adult men in rural communities
have iron deficiency anaemia, one of the most extensive nutritional deficiency disorders in
the country.
Vitamin A deficiency is very high among preschoolers especially in rural areas and slum
dwellers and over 54.3 million people are estimated to be affected by iodine deficiency
30
disorders including goitre in more recent surveys. While food production has gone up and
we are now self-sufficient maldistribution continues to be a major problem. Micro studies
have shown that diets of female children and women are still inadequate because of
discrimination in Indian household food allocation. Nutritional problems thus remain a
major health challenge linked closely to factors in the socio-economic and cultural milieu
of the country.
B. Communicable diseases
Various communicable diseases continue to contribute to the mortality and morbidity of
the population in India. These include the following:
Malaria has shown a drastic decline since the 1970s as a result of a national
control programme. In 1971, there were 1.322.000 cases of malaria which rose to
6.467.000 in 1975-76 and has presently declined to 1.744.000 cases in 1985,
causing much continuing concern. There are around 2 million cases per year since
1985. "
Tuberculosis continues to be a major problem. It is estimated that 1.5 % of the
population is infected (12.7 millions infected and diseased). In 1992-93 1.539
million cases were detected.
Leprosy: it is estimated that there are 1-3 million cases of Leprosy with a
prevalence rate of over 5/1.000 in around 201 districts. The states which have the
largest reported numbers are Tamil Nadu, Andhra Pradesh, West Bengal, Uttar
Pradesh, and Maharashtra.
Filaria occurs in 175 known epidemic districts and estimates vary.
STD's affect 20-30 million people according to expert estimates.
Kala Azar (Visceral Leishmaniasis) has shown a resurgence in some endemic
districts of Bihar and West Bengal. 77.101 cases and 1.419 deaths were reported in
1992-
Cholera is also showing a resurgence especially in some endemic urban pockets,
while dianhoea and dysenteric diseases continue to take a heavy toll, especially in
children.
HIV-Infection has now been reported from as many as 23 states and union
territories in the country with the highest incidence from Maharashtra, Tamil Nadu
and Manipur. In the former two states the pattern of infection is through sexual
transmission while in the northeastern states it is probably linked to drug abuse. Of
1.898.670 persons screened for HIV by September 1993, 13.294 were found to be
seropositive. According to expert estimates the number of infected persons by end
of 1990-92 was about 1 million.
C. Non-communicable diseases
Cancer, heart disease, mental health and occupational health problems are increasingly
recognized as important public health problems. Blindness is a major disability with
estimates of around two million cases of cataract induced blindness annually though
preventable causes like vitamin A deficiency and injuries continue to be significant as
31
well. Accidents and injuries, particularly occupational, are another major cause of
morbidity in the working age-groups. While the earlier decades saw a major emphasis on
national communicable disease control programmes, the last two decades have seen the
evolution of many national programmes for these non-communicable diseases as well.
D. Other major problems
According to the 1981 census there were 11,2 lakh cases of disabled and handicapped
persons in 1980 (about 171 per 1.000 population). 87% are in rural areas. Of these 171
per lakh of population, 73 were blind, 42 dumb and 56 physically handicapped. Other
estimates here suggested that 18% of the population are disabled.
Another major problem is access to safe water and sanitation. The 1981 census showed the
following state of water supply and sanitation in the country:
Population
Rural
Urban
Combined
With water supply (%)
With sanitary facilities (%)
30.9
0.5
77.8
26.9
41.3
6.4
While the rural areas are still very bad off, the urban areas do not reflect properly the
inadequacy of water supplies and sanitation facilities for the urban poor who live in slums
and shanty towns. Due to their low paying capacity and to the problems regarding legality
of settlement patterns a large percentage are deprived of basic amenities.
In 1980 a government survey identified 2.31 Lakh problem villages. The problems were
of three types:
1.
2.
3.
villages which do not have a source within a distance of 1,6 km. (criterium 1);
villages where existing water sources contain excess salinity from fluorides, and
other toxic elements (criterium 2);
villages where existing water sources were prone to cause diseases like cholera and
guinea worm (criterium 3).
In response to this high-priority problem the government declared the decade 1981-*91 as
the water and sanitation decade. A National water supply mission was then established to
provide safe drinking water supply to rural areas. By 1992-’93, out of a total of 583.000
villages in the country 582.250 were provided with drinking water facilities fully or
partially. During 1992-’93, 2.218 no source villages were provided with safe drinking
water and 32.157 partially covered villages were also given additional sources.
The Eighth Five Year Plan (1992-'97) aims at covering the no-source villages, providing
sustainable supply of safe water to the no-source habitations, completing eradication of
water borne diseases, enhancing quantum of supply and quickly, securing scientific inputs
into rural water supply programmes and improving the operation and maintenance of water
supply sources. The master plan also aims to get urban water supply to 100% and urban
32
sanitation to 80% soon.
In summary: while statistics on morbidity patterns are increasingly available and
improving in quality and validity, what is emerging is that the health status in India shows
all the major problems related to poor nutrition, poverty and poor environment continuing
as major public health challenges. These are however co-existing with most of the
non-communicable- diseases of the developed world increasing the overall burden on the
health services.
3.6.
Primary health care services and national programmes
A. Primary health care services
Based on two expert reports (The Bhore committee report, 1946 and the Sokhey
Committee Report; both pre-independence), the Government of Independent India
launched a massive programme for the establishment of Primary Health Centres (PHC’s)
from 1952, covering initially 100.000 population with sub-centres at 10.000 population
level.
The primary health centres were envisaged to have doctors, nurses, lady health visitors,
auxiliary nurse midwives, sanitary inspectors, block extension educators and basic health
workers. This pattern was adopted all over the country and adapted by each state in terms
of levels of coverage by PHC’s and subcentres, according to local needs and resource
availability.
Initially, the health workers, especially the male workers were unipurpose focusing on
special problems like malaria, filaria, trachoma etc. In the early ’70s, the whole PHC
concept was reviewed and all unipurpose workers were retrained as multipurpose workers
and the whole distribution and function and supervision was rationalized.
Now primary health centres range between coverage of 50.000 and 80.000 population and
subcentres from 5.000 to 10.000. At least three doctors are posted to the centres - one
senior medical officer, one lady medical officer especially in charge of mother and child
health and family planning, and one other medical officer who may be involved with
training of health workers or may be of an alternative system of medicine. The subcentres
have at least one male and one female multipurpose worker and groups of subcentres are
supervised by male and female health supervisors. This is the basic pattern but there are
variations and diversities in the different states.
In 1977, the government launched the community health guide scheme which was aimed
at identifying and training at least one community-based volunteer for every 1.000
population in basic health care needs. This scheme was taken up by some states only.
Training of traditional birth attendants was also adopted as a programme in the 1960s, but
it got greater emphasis in the later decades. In recent years the CHG scheme has been
somewhat neglected.
33
In the early 80s, the government has initiated a plan to upgrade every 4th PHC to a 30bed hospital with some specialists in the basic disciplines of medicine, surgery, obs. and
gyn. and paediatrics, but this scheme is progressing very slowly.
B. National programmes
Over the years the government of India at the centre has launched a number of national
programmes to deal with specific diseases and health problems. While these are vertical at
the centre and state ministry level they integrate into the primary health centre system as
multiple functions of the centres and staff at each level.
The programme planning, organization and implementation and evaluation is carried out
by experts both at the central and state directorate levels and the specialized National
Training and Research institutions. The special national programmes sponsored by the
Central Health Ministry include among others programmes for eradication of malaria and
leprosy, control of tuberculosis, filaria, kala-azar, STD, AIDS, control of blindness, goitre,
cancer, guineaworms and mental health programmes. In addition, family welfare, universal
programme of immunization against six vaccine-preventable diseases, vit. A and iron and
folic acid supplementation programme, ORT and diarrhoea control, ARI control and
training of TBA's programme have been more recently grouped under the CSSM group child survival and safe motherhood programmes.
There are growing concerns in India that some programmes like the expanded programme
of immunization (supported by UNICEF) and family planning programme (supported by
USAID and other agencies) are promoted with a zeal, overriding focus and targetoriented, top down and vertical process that affects the other programmes and diverts the
attention of the health team. Apart from raising concern about the abilities of international
bilateral and multilateral funding agencies to skew priorities by funding decisions and
selectivizing primary health care, this trend also causes various management problems
affecting other programmes and priorities. The World Bank supported AIDS Programme is
a new one and is beginning to show the same trend and potentiality.
3.7.
Population, development and family welfare
A. Population and development programmes
The development process in India has tried to gradually reduce the proportion of people
living below the poverty line, with different degrees of success and failures in various
regions (poverty line: annual income of Rs 11.000 or less). Since over 40% of the world’s
absolute poor live in India, special efforts have been initiated to provide a social safety
net. These include:
1.
2.
A public distribution system (PDS) providing subsidized food for the poor;
The Integrated Child Development Services (ICDS), which provide basic health,
nutrition and education packages to mothers and children, (it now reaches 15
34
3.
4.
million children and 3 million mothers);
The Integrated Rural Development Programmes (IRDP) providing subsidies and
loans to low-income rural households to get productive assets;
The Jawahor Rozgar Yojana (JRY) a wage employment programme for
disadvantaged groups;
50% of IRDP programmes are expected to be weaker sections of society (scheduled castes
and tribes) and 40% is earmarked for women. Two additional sub-schemes complement
the effort. Training of rural youth for self-employment (TRYSEM) and development of
women and children in rural areas (DWCRA). TRYSEM trains 2-3 lakh youth each year
and DWCRA has formed 57.000 groups (987.000 members) of women for income
generating activities.
These programmes are supplemented by additional schemes focused on the more difficult
districts. The Employment Assurance Scheme (EAS) seeks to provide assured wage
employment for 100 days a year during the agricultural season; the National Water Supply
Mission to provide water supply to 'no source' villages, eradicate water-borne disease and
enhance quality and quantity of supply; The National Education policy which includes
among other steps priority for rural schools and motivation centres programmes for
promoting self-confidence and self sufficiency among women.
The progress of these programmes has shown varied successes as well as the identification
of operational problems. Poverty has however diminished, in spite of population growth.
Incidence of rural poverty fell from 51,2% (1977-78) to 33% (1987—‘88) and urban
poverty from 41% (1977-’78) to 20% (1987—’88).
National level statistics about poverty and the economic situation, the levels of agricultural
development and the levels of infrastructural development hide the glaring disparities and
regional diversities that occur in the country. Land use patterns are diverse reflecting a
diversity of agricultural incomes. This is further complicated by differences in rainfall
patterns and drought and desert proneness of regions.
State governments have invested in infrastructure development to varying extents.
Complicating the 'poverty problem' are other social issues of marginalization, like
variations in percentage of scheduled castes and tribes, levels of urbanization and levels of
labour bondage. Poverty alleviation programmes therefore cannot be just economic and
technological packages, but need to be deeply rooted in the local sociocultural and
development diversities.
These gains in development are bound to have their effect on population growth and
health status which will become more evident in the years to come. However, close
monitoring and supportive supervision and continuous orientation of government
functionaries will be required to ensure that the gains are not in paper but in actual 'on the
ground realities’.
35
B. Family planning (welfare) programme
Family Planning and population issues have been a high priority concern of planners in
India since independence. In 1951, India launched the first official Family Planning
Programme in the world. The objective was to 'reduce the birth rate and to stabilize the
population at a level consistent with the requirement of the national economy'. The
programme evolved in phases starting with the clinical approach, then the extension
education approach and the 'cafeteria' or 'choice of alternatives' approach. A national
policy statement in 1976 affirmed the priority and commitment of the Government to this
important issue. The National Health Policy (1981—’83) set the demographic goal to
achieve a net reproduction rate of UNITY (NRR-1) by the year 2000 AD. This means a
crude birth rate of 21 per 1.000, a crude death rate of 9 per 1000 and a natural increase
rate of 1,2% . The policy also aims at reducing IMR to below 60 per 1.000 live births.
More recently this date has been shifted to the year 2011. Recently the National
Development council, an apex planning body chaired by the Prime Minister, has set up an
expert committee to formulate a national policy reviewing the past, assessing the present
and planning effectively for the future.
Family Welfare Programme aims to provide family planning services within the broader
context of MHC care. It disseminates information and organizes services to enable couples
to make voluntary and informed choices regarding size of family, spacing and contracep
tion. Links are establishes with other development programmes in the areas of education,
nutrition, poverty alleviation and minimum needs. The programme includes primarily the
provision of MHC and FP services through the large network of PHCs and subcentres,
supplemented by training of personnel and infrastructural development. The methods
promoted are sterilization, condoms, IUDS and oral pills. Recently injectables and inplants
have also been introduced. The supplement gives as idea of the couple protection rates and
level of acceptance of methods.
(
As part of an overall strategy to reduce IMR and MMR and complement the programme,
the Universal Immunization Programme for six vaccine preventable diseases in children
and tetanus toxoid for pregnant women has been introduced. A new child survival and safe
motherhood project (CSSM) is under implementation since 1992-'93. Apart from
sustaining high coverage of UIP it also provides ORT, prophylaxis schemes for control of
anaemia in children and pregnant women, control of blindness in children by vitamin A,
supplementation and control of ARI in children.
Training of traditional birth attendants and provision of aseptic delivery sets, and
strengthening of first referral units to deal with high-risk pregnancies and obstetrical
emergencies are also components. Medical termination of pregnancies on health grounds is
now legally permissible and provided for as a safeguard against clandestine abortion under
unhygienic conditions. The whole programme is also linked to a massive information,
education and communication strategy that includes both modem media and traditional
media.
36
3.8.
Supportive services and structures, and additional sectors
A. Human power planning and health team training
A large country like India needs a massive human power training programme, and since
independence a very large number of medical colleges, nursing colleges, dental and
pharmacy colleges and rural health and family planning training centres have been
established (to train health workers). The country has around 140 medical colleges, about
10 percent of the 1.400 medical colleges in the world. It produces annually over 14.000
doctors and the present doctor population ratio is 1:2412 (1986).
Though there is a large rural-urban differential with the large majority of doctors
preferring urban practice of all types, there is growing concern that we are producing more
than we can absorb and much of this is at the cost of investment in training of other
members of the health team. There has been a large gap in the investments in nursing
colleges (nursing education), and both staff nurses and nurse midwives are inadequate in
numbers. Some efforts are underway to remedy the situation in the next plan period.
Continuing education of the health team is another major lacuna, and the present efforts
are inadequate. The government has evolved good training manuals for all categories of
the health team which reflect primary health care priorities. However, the quality of
training is very variable at the state levels, and at all levels of training this quality
differential exists.
National councils regulating standards exists. These include the Medical Council, the
Nursing Council, the Dental Council, and the Pharmacy Council.
)
B. General Practice
India has a very large number of doctors trained in different systems of medicine,
providing service to the community as primary level general practitioners. In 1984 there
were about 702.000 registered medical practitioners, of which 42,3 percent were allopaths,
40,3 percent were trained in Indian systems of medicine and 17,4 percent were
homeopaths.
All these practitioners do not come under any organized National Health Service, and
private practice is totally unregulated. There are professional associations, with the
allopaths being more organized than the other systems but these tend to be more 'pressure
groups' rather than self regulatory associations or forums for continuing education and
maintenance of standards of care.
The health policy makers gave inadequate attention to this sector till the 1982 health
policy, though even now their involvement in primary health care priorities and national
programmes is still relatively marginal. They are mainly involved, if at all, in
immunization and family planning work. Unregulated practice also makes this sector open
to irrational practices in prescribing and investigation. The ICSSR/ICMR expert study
37
group on Health for All - an Alternative Strategy - has noted that 'Eternal vigilance is
required to ensure that the doctor-drug producer axis does not exploit the people’ and the
abundance of drugs does not become a vested interest in ill health’.
C. Secondary Care Services
The large number of primary health centres are linked to secondary level hospitals at
district levels and in all major towns and cities for medical care referrals and to district
level referral centres and resource teams/units coordinated by the district medical officer.
Plans to upgrade every 4th PHC to a small 30-bed hospital (community health centres)
with four doctors - a surgeon, obstetrician, physicians and pediatricians - have been
initiated but they are progressing very slowly because of the reluctance of clinicians to
work at the primary level.
At the secondary level there is also a large network of private hospitals and an increasing
number of nursing homes and polyclinics, though they too show an urban bias and do not
go beyond the district headquarters. The mission hospital sector was initially a response to
the lack of health and medical care in the more disadvantaged areas of the country but this
is fast changing with the mission network in a financial crisis and unable to handle the
evolving pressures of the medical market economy.
D. Tertiary Care
The government has also invested gradually in a large number of specialized centres
offering specialist services and tertiary care referral support to the health centres and
hospitals. These are all city-based, mostly in state capitals and - as in many parts of the
world - tend to draw much more of the support required from an overall limited health
budget.
While many of these are of good quality and provide very good facilities for postgraduate
training many if not most of them tend to ’transplant ideas' from Western hospitals and are
not adequately focused on priority health problems or on the evolution of appropriate
technological responses that would cater better to the socioeconomic, cultural,
geographical and logistical challenges of primary health care in the country.
E. The private sector
Apart from the army of general practitioners most of them outside the government health
systems mentioned earlier, the country has a very large number of private hospitals,
dispensaries, nursing homes and polyclinics (already mentioned in secondary care). In
recent years there has been a mushrooming of high-tech diagnostic centres and super
specialist hospitals supported by the corporate sector and massive NRI (Non-resident
Indian) initiatives. Medical business is booming, and while the country can now boast of
having every type of high technology and super specialist care, this is not accessible to the
large majority, and the costs are increasing.
38
i
The private sector is estimated to include over 55,5 percent of the hospitals and 55,3
percent of the dispensaries in the country as of January 1990.
Considering that private sector health is totally unregulated and has till very recently been
totally ignored by national health planners, there is a growing concern that this
unregulated sector will grow even more significantly because of the new economic policy
and its commitment to market economy and privatization. The concern is not so much
against the private sector per se, but about what importance it will give in the future to
preventive medicine, public health priorities and primary health care, which it has totally
ignored so far.
F. Research institutes
The country has established a network of national research and training centres linked to
the Indian Council of Medical Research (ICMR). These include the National Institute of
Health and Family Welfare, Nutrition, Tuberculosis, Communicable disease, Environmen
tal Health, Occupational Health, Reproductive Health, Vector Control, Mental Health and
Neurological sciences, Leprosy, Immunobiological research, Speech and Hearing and
Cancer. The ICMR also supports research in many other institutions, primarily medical
colleges. The quality of research in many of these institutions is of a high standard and
good contributions, especially applied aspects in the field have been made, including field
guidelines for various national programme and orientation training for health teams at
different levels.
Health practices research, epidemiological research and health policy research however
have not received the important emphasis they should have been given, considering the
health care challenges and problems in a country with phenomenal regional diversities and
disparities.
G. University linkages in Health team training
Education is a state level responsibility and the central government can only lay down
standards and norms for training institutions and curricula. All medical, nursing, pharmacy
and dental colleges are affiliated to various universities in each state. Recognition by the
National level councils however ensure that qualifications are recognized in all parts of the
country. Paramedical training may or may not be affiliated to universities. There are
plans to evolve a National education council that will plan for human power needs and set
guidelines for training in the future.
H. National Health Service
While the Health Ministry at Central and state level through the health directorates
organizes and maintains the network of subcentres, primary health centres, dispensaries
and hospitals there is no National health service in the European (UK) sense covering all
the population and bringing all services under a single planning and regulating authority.
39
Like the general economy in India, Health care is a mix between the government and the
private sector, and a small voluntary sector as well (NGOs).
All Central government employees all over the country are covered by the CGH Scheme
(Contributory Government Health Scheme) provided by a network of dispensaries and
hospitals, and affiliated institutions and recognised practitioners. Similarly all factory
workers, especially in the public sector and in the medium to larger private sector are
covered by the Employment State Insurance Scheme (ESI Scheme). Both these schemes
are like the UK-NHS but cover only smaller sections of the population. The agricultural
sector and most of the other unorganized sectors like constructions workers and small
scale establishments are not covered by any specific schemes. They have to utilise the
services of the general government hospitals and dispensaries.
I. Occupational health
The ESI scheme, though occupational in focus, does not provide adequate occupational
hazard-related services though some prevention and protection measures are provided. The
National Safety Council and Central and regional labour institutes and the labour
inspectorate do recommend and supervise some occupational health measures but much
more needs to be done.
An important area of priority concern is the continuing situation of child labour. In the
1981 census there were over 11,2 million children who were involved in employment.
While the large majority were in the agricultural sector there were other areas of special
focus like the match/firework industry in Sivakasi (Tamil Nadu), the carpet weaving and
brass industry in Uttar Pradesh and others which have a larger child labour and are
dependent on it. The recently enunciated national policy for children has now identified it
as an important goal that 'no child under 14 years shall be permitted to be engaged in any
hazardous occupational or be made to undertake heavy work'.
J. School health
The Primary Health Centres and the government dispensary medical offices are supposed
to provide a school health service for the government schools in their area. This usually
means an annual check-up and some immunizations. In the voluntary sector there has
been some interesting attempts to enhance the educational aspects of school health
programme and bring in child to child concepts and some state governments have shown
an increasing interest in these as well. In Andhra Pradesh there is a better organized
School Health programme supported by ODA (UK).
3.9.
Health finance
This is an area that is beginning to receive much more attention in recent years and policy
planners and researchers are beginning to focus more specifically on financial systems,
costing of health care, cost recovery, low cost alternatives and studies of patterns of
40
expenditure on health care at individual family and community levels. Only some salient
points will be outlined in this review:
1.
2.
3.
4.
5.
6.
7.
Allotment for health care including medical care, family welfare, public health
programmes, water and sanitation etc have gone up progressively in each plan
period with the present expenditure being over 8.200 crores in 1991-92 (Per person
Rs. 95,81).
The estimates for private expenditure on health, based on various indirect estimates
for the same year 1991-92 was 9.022 crores (per person Rs. 105,40).
The 7th plan outlay for health, family welfare and water supply and sanitation is
about ten times the 4th plan outlay showing increasing investment by the
government (to approximately 3+ percent of total plan outlay). However, it is still
not as high a percentage of total development expenditure as is seen in some of the
other Asian countries who have shown a major priority expenditure on health and
education service.
The per capita state incomes are quite variable but some states like Tamil Nadu,
Kerala, Karnataka, show greater per capita state expenditure on health, with better
dividends in health status indicators.
Levels and patterns of household expenditure on health care are being studied, and
in recent studies the major role that the private sector plays as a health provider is
being documented. While government health care is estimated to cover 13-15
percent, people are using the varied alternatives in the private sector to about 77
percent. The study also showed that 5,75 percent of the total annual household
income was spent on health-related expenditure or an estimated Rs 183 per person
per year; and much of this on consultation fees and drugs (66 percent).
While the voluntary sector serves or covers only 5 percent of the population, some
recent studies done by VHAI/Ford Foundation have shown that they tend to
provide low-cost services as compared to the public and private sector. Studies
have also shown that this sector taps a number of different sources of revenue to
fund health activity - government grants, foreign donations and community and
self-financing funds and usually also tap more than one source. This was the only
sector that has also some experience in innovative financing methods that include
fee for services, prepayment schemes, health cooperatives and running commercial
activities to support health care. Realizing that self-financing initiatives can often
exclude the poor and marginalized, many voluntary organizations have been
experimenting with innovative ways to protect or subsidize poor patients. Further
studies of these innovative experiments need to be done. Financial recovery
schemes, supported by greater initial investments and built in social safety nets for
the poor need to be further researched in the years ahead.
While financing health care is receiving greater attention the new economic policy
with its focus on privatization and liberalization may convert health care into
medical business at the cost of primary health care and public health services to the
detriment of the needs the large majority who are marginalized in the country. This
will remain a major challenge to health planners in the 1990's (see later section).
41
3.10.
Traditional systems of health care/ISM
India has a number of systems of medicine and folk health practices that have developed
over the centuries, as people tried to alleviate the sicknesses that they fell prey to. The
foremost among the classical Indian Systems is "Ayurveda" - The Science of Life. This
is a well-developed body of knowledge which has many specialities including an
extensive pharmacoepoea, surgery, care of children, women etc. It requires a formal course
of study for which there are several existing colleges even today. The principles and
practice of health lifestyles was also considered very important and responded to the
prevailing circumstances. Elaborate details regarding types of diet during different seasons
and in different physiological conditions, during pregnancy etc., have been prescribed.
"Yoga" which harmonises physical, mental and spiritual health and is used to promote and
maintain good health, is also an ancient science. It is getting better known both in the
country and elsewhere. The other classical systems are "Siddha" medicine practised
particularly in the South Indian State of Tamilnadu, and "Unani". Unani developed from
the Arabic System of Medicine which was introduced by the Moghuls but which
interacted closely with Ayurveda.
Homeopathy is fairly widely practised in India today and acupuncture, accupressure etc.
are also gaining wider popularity. Several other forms of healing are being used particu
larly by the richer urban groups eg., magnetotherapy, naturopathy, holistic health etc.
Having links with Ayurveda, but responding to local situations and disease patterns are
what are known as Lok Swasthya Paramparas' or folk health practices. These are
extremely widespread and used commonly even today. Their practitioners would include
the more informal healers like bone-setters, traditional birth attendants, specialists in
snake and insect bites, herbalists etc. They acquire skills through oral handing down of
traditions and through experience. These are really our front line primary care workers. Of
course, even earlier come the grandmothers’ remedies or home-remedies used widely by
people for minor ailments. There is fairly widespread knowledge regarding these
remedies, being spread between persons and generations by word of mouth.
Increasing recognition is more recently being given to the contribution of this entire
traditional indigenous health care sector. During the later period of colonialism, this group
was looked down upon and their practitioners were considered as quacks and even banned.
After Independence also they were not taken seriously and Indian Systems of Medicine
(ISM) were allotted only 5% of the total health budget. However, studies have shown that
80-85% of the population actually use the services of this sector. They are more
accessible to people, available where people live, cheaper and culturally acceptable. Indian
Systems of Medicine and Homeopathy will have to be taken more seriously in this decade,
because the quantity and quality of the infrastructure and human resources available is
now better known and the ground realities can no longer be ignored by the health
planners.
At the grass root levels, there are an estimated 7 lakh midwives, 60.000 village home
setters and 60.000 herbal medical healers apart from millions of housewives with
knowledge of home remedies and therapeutic diets. Non-governmental ISM centres and
42
clinics are present all over the country but no clear estimates at all-India level are
available on their extent, types and structure. But there is evidence that states such as
Tamil Nadu Kerala and Gujarat have a fairly good tradition.
Official institutions for ISM set up by Government/Private (1987) include 225 colleges of
which 95 are Ayurvedic; 17- Unani; 1-Siddha and 112-Homeopathic colleges. There are
25 postgraduate institutes as well of these Ayurveda has 22, Unani have two and Siddha
system has 1. The government has also set up Central Research Councils for all the
systems; thirteen state run pharmacies; and a network of small rural dispensaries are
present in some states.
The network of practitioners of ISM is a very large one. The Ministry of Health and
Family Welfare has estimated in 1987 that there were 404.856 registered practitioners of
which Ayurveda doctors were 243.153; Unani 28.021; Siddha had 11.500; Homeopathy
has 122.173. Professional associations of ISM practitioners also exist.
It has also been estimated that there are 1.776 hospitals of ISM with 21.116 beds (in
1987), and about 14.434 dispensaries.
More recently a national network of medical professionals and others who believe in the
integration of ISM with the National Health Care System has evolved entitled LSPSS (Lok
Swrasthya Parampara Samvardhan Samiti).
State government allotments for ISM show the same regional disparities as in many other
aspects of Indian health care. Kerala allocates 13 percent of the medical budget while
West Bengal allocates less than one percent. The States most responsive to ISM’s are
Punjab, Gujarat and Maharashtra.
3.11. Voluntarism and health care alternatives
Since several decades there has been the phenomenon of non-governmental organizations
(NGOs) or voluntary groups working in the field of health care. The traditional sector
already mentioned has been the mainstay of health care in the villages. They are part
voluntary, being extremely low-cost, often taking payment in kind whenever it is
available. This tradition continues and functions in a decentralized fashion, being part of
rural life. The system is breaking down or is non-existent today in urban areas including
urban slums. The urban population is estimated to increase to 40% by the turn of the
century. This is therefore an important lacuna which has no ready replacement.
More institutionalized forms of voluntarism or voluntary work have also developed. These
are often linked to religious groupings, e.g. Buddhist, Jain, Muslim, Sikh, Hindu and
Christian. Gandhian groups and several charitable trusts and societies also are involved in
a range of health work. To give an indication of the quantum, 20% of the total hospital
bedstrength of the country is run by the voluntary sector. This sector essentially runs on a
not-for-profit basis and provides fairly good quality service that is available to the poor.
If one considers out-patient medical services, community health and development work,
health education and awareness raising, the contribution of the voluntary sector is even
43
greater. There arc estimated to be about 7.000 voluntary agencies/groups in the country
working in the field of health.
Interestingly, the government looks rather favourably to the work of the voluntary sector.
During the past decade it is providing increasing scope for participation of the voluntary
sector in various capacities. It even channels funds to the voluntary sector.
Among the strengths of the voluntary groups are that they are flexible, innovative,
committed and they identify fairly strongly with the poor. They are involved with a very
wide range of involvements. These include:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Provision of curative and preventive health care accessible to the poor especially in
remote areas/difficult terrains. In this area there has been very successful
experimentation with the training of community health workers, who can provide
treatment for minor ailments. They also undertake health education, follow-up
patients with TB and leprosy, make use of facilities provided by the government
and organize peoples' groups. Training by dais (traditional birth attendants) to
improve the quality of their servies and to link up with referral services of the
government and voluntary sector has also been done. The government has taken up
the above concepts and introduced them on a nation-wide level even before the
famous Alma Ata conference.
Evolving innovative health financing schemes eg., health insurance, linking to
cooperatives etc.
Building on local health knowledge and skills - using herbal remedies, studying
folk health practices and strengthening those found to be beneficial.
Promoting low-cost, appropriate health technologies, e.g. the use of home made
oral rehydration solution, use of nutritious supplements using locally available
foods, use of nutrition bangles for assessment of malnutrition.
Focus on mother and child health and of late on women's health. Child to Child
health programmes are also being tried out.
Use of folk media/low-cost media for communication of health messages, e.g.
dance dramas, puppetry, harikathas, songs, nachnas, street plays etc.
Some groups work in specific areas like leprosy control, TB control, provision of
sanitation/water supply. The current trend however is to integrate activities.
Working with the disabled, working in the area of mental health, working with
street children, focusing on alcoholism, drug addition, AIDS etc., are all areas in
which NGOs make a small but significant pioneering contribution.
Many groups working at the grass roots realise that health work cannot be done in
isolation from other aspects of life. Also that medical work alone brings about
only a minimal improvement in the lives and health of people. Therefore, several
programmes which have a health component have also introduced other aspects e.g.
promotion of kitchen gardens with plants whose products have good nutritional
value, promotion of smokeless chullas (cooking places) which prevent a number of
respiratory problems, gobar gas plants in which cowdung and organic refuse is
used to generate energy in the form of gas which is used for cooking/lighting etc.
Others are involved with a variety of educational programmes like non-formal and
adult education, vocational training etc. Still others have agricultural programmes
or other income generation schemes, small saving schemes etc.
Yet other groups focus primarily on community organization - formation of mahila
44
12.
13.
mandals or women groups, youth groups, farmers groups, fishermen's groups etc.
From this has evolved an understanding and respect for the peoples' own
knowledge systems and the evolution of participatory training programmes, where
there is mutual learning and growth. Building further on this are participatory
methods of evaluation and research.
Issue raising groups among the voluntary sector raise critical issues regarding the
national health policy. They attempt to bring into focus the need for a rational drug
policy, women's health issues, needs of tribal groups, urban slum populations etc.
Thus in more recent years the voluntary sector has began to search for and
experiment with alternative approaches to health care. These attempt to evolve
initiatives relevant to our own sociocultural, political and ecological milieu.
3.12. National level voluntary organizations
At the national level there are many coordinating, networking associations providing
linkages between voluntary efforts. The key ones include:
1.
2.
3.
4.
The Christian Medical Association of India (CMAI) was formed in 1921 and links
the personnel in institutions related to the Protestant and Orthodox Churches in
fellowship and professional growth. This is provided through workshops, meetings,
consultancies and publications. It promotes all the components of Primary Health
Care. It is involved with emerging health problems of AIDS, substance abuse etc.
The Catholic Hospital Association of India (CHAI) formed in 1943, today has 2304
institutional members spread across the country. These are primarily health centres,
dispensaries, hospitals, social welfare centres with health programmes or and social
services societies. CHAI provides continuing education to members through
workshops, seminars, annual conventions and a publication section. It promotes
community health in its broadest sense. In recent years the focus has been on use
of herbal and non-drug therapies and health work among the urban poor. It
provides assistance (with partner agencies) for supply of medicines, equipment etc.
to all voluntary organizations.
The Voluntary Health Associations of India (VHAI) was formed in 1974. It grew
from the efforts of the above two associations. It is a federation of 18 state level
voluntary health associations. It is secular in character. Approximately 3.000
voluntary health institutions/groups are members of the state level associations. It
focuses on community health and on interaction with government. During the past
decade it has been lobbying and doing advocacy work on various public policy
issues like need for a rational drug policy, against pesticides and tobacco, against
commercialized high-cost baby foods etc. It has also initiated lobbying with
parliamentarians and political parties regarding health issues. It organizes training
programmes in community - and school health and focuses on use of traditional
medicine. It has a creative publication division producing materials in different
Indian languages.
The Medico Friend Circle (MFC) is a national group of individuals who share a
common concern and interest in reshaping the health system in India to meet the
needs of the majority who are the poor of the country. The groups is primarily a
thought-current. Individual members give shape to and internalize the perspectives
45
5.
in their own work and in other groupings to which they belong. A few of the
common actions undertaken by the group included community based research in
the aftermath of the Bhopal disaster and lobbying for a rational drug policy.
There are many other associations at the national level which focus on specific
health problems eg, family planning Association of India (FPAI), National
Tuberculosis Association etc.
3.13. International funding agencies
India receives external assistance both from multilateral and bilateral agencies for
strengthening the Family Welfare programme primarily and many aspects of other national
health programmes complementarily. UNFPA assistance is utilized for three area project in
the states of Rajasthan, Himachal Pradesh and Maharashtra. WHO assistance is utilized for
purchase of supplies and equipment, and training of manpower and related consultancies.
UNICEF assists the Child Survival and Safe Motherhood Programme (CSSM). World
Bank assists India population projects in 11 states and 2 cities (Service delivery
enhancement, infrastructure development, training) and CSSM. NORAD supports post
partum programmes at subdistrict level (1012 centres) and innovative intervention pro
grammes in Orissa and Karnataka. DANIDA supports Integrated Development projects in
districts of Madhya Pradesh and 2 districts of Tamil Nadu. ODA (UK) supports area
development projects in 5 backward districts of Orissa. World Bank supports development
of services in the urban slums of Delhi, Calcutta, Bangalore and Hyderabad, in entire
Assam and 10 lagging districts of Karnataka and 10 desert districts of Rajasthan, and a
special social safety net scheme in 90 demographically poor performing districts (involves
upgradation of MHC/FW services) are also in various stages of evolution.
In the health programme sector, World Bank supports MDI for Leprosy Control Program
mes, supports national blindness control programmes; the development of secondary level
hospitals in Andhra Pradesh; and more recently a massive project for prevention and
control of HIV infection. Other agencies like DANIDA support leprosy eradication and
blindness control; SIDA supports leprosy eradication and TB control and NORAD sup
ports MDT activities in leprosy control. ODA (UK) supports six research projects in area
like cervical cancer, haemoglobinopathy control, Rotavirus infection, chlamydial lab
project, viral hepatitis and study of gene products of mycobacterium leprae. It also
supports the Andhra Pradesh government school health programme.
The multilateral and bilateral agencies support to health and family welfare programmes is
appreciated as a partnership in the country's efforts to tackle challenging health and popu
lation problems. However, there are growing concerns that these agencies thrust agendas,
experience, models and market economy solutions that are not always in touch with local
realities or suited to the local milieu. In some cases they are also based on rather
inadequate epidemiological evidence and extrapolations from experience in other parts of
the world not necessarily relevant to the Indian situation. Foreign experts and academics
often use these funding opportunities to try out ideas and methods not rooted in Indian
analysis and field experience. Funding 'muscle' also ensures that local expertise is not
adequately tapped. The problems of partnership need constant review and dialogue. The
challenge of the 1990s is to find 'spaces' and 'fora' for this sort of partnership evaluation.
46
India has a very large network of voluntary agencies (NGOs) which are also supported by
both local funds and charities and foreign funding agencies. Among these there are a large
number of groups, big and small, from all parts of the world. The most well known are
Oxfam, Action Aid, Care. In the Mission sector MISEREOR, Cebemo, EZE, Bread for the
world, MEMISA, HIVOS and numerous European agencies are important partners. More
recently support from North American sources has increased. The support process in this
sector has shown a gradual shift from infrastructural development to programme support
aid, human resource development (training) and more recently to community organization
and empowerment activities. Some support to networking, continuing education, alternative
research and issue raising/lobbying activities have also been available.
The project orientation of most of these funding partners (rather than social process
orientation), the scaling-up pressures on NGOs (to reduce administrative costs of funding
agencies) and the professionalization and perhaps market economy related competition and
other factors are bringing about changes in the ideology and orientation of NGOs in the
country. These are therefore now, not necessarily always focused on a more poor or
pro-marginalized group related problems. Funding agencies need to constantly monitor
and review their support to ensure that they fund processes and initiatives rooted in a
deeper sociocultural, political, economic and ecological assessment of the country's or
region's needs and potentialities.
Focusing on quality rather than quantity; regional long-term initiatives rather than multiple
micro-short term projects inputs all over India and supporting continuing education and
measures toward sustainability will be the challenges in the 1990s. All regional and local
and national partnerships in health care and community health action will have to
emphasize and facilitate this aspect further without getting pre-occupied or side tracked by
the market economy factors of competition, institutional development or sectoral politics.
3.14.
Issues and challenges in health policy development
A. Recent developments in health policy
At the Silver Jubilee of India's independence in 1972, the government initiated a process
of review and retrospection of the first 25 years of development planning, since 1947.
Various aspects of the health care system were reviewed, particularly the policies on
human power development. The Srivastava Report (1974) an expert committee on Medical
Education and Support Manpower while making some far-reaching recommendations on
reorientation of medical education, training of village based health workers (Community
Health Guides) and the building up of referral services complex between peripheral and
district level hospitals, also raised some serious misgiving about the model of health care
that had been adopted from the West. It noted that health was wrongly defined as
consumption of specific goods and services; that overprofessionalization increased costs;
and that autonomy of individuals was getting reduced. It was therefore recommended that
we should 'strive to create a viable and economic alternative suited to our conditions needs
and aspirations'.
47
India was a co-signatory of the Alma Ata declaration and in 1981 an expert study group
jointly facilitated by the Indian Council of Social Sciences Research and the Indian
Council of Medical Research was requested to recommend an alternative strategy for the
'Health for AH' goal. This group was also highly critical of the system that had been
developed since Independence. The model of health care was found to be 'topheavy,
overcentralized, heavily curative, costly, urban, elite-oriented, dependency creating and
inappropriate'. It warned against small and well-meant reforms and suggested a radically
different alterative community health strategy. Its prescription included:
1.
2.
3.
a mass movement to reduce poverty, inequality and spread education;
an effort to organize poor and underprivileged to fight for their basic rights;
A concerted effort to move away from the counterproductive Western model of
health care and replace it by an alternative based in the community - which it
outlined in some detail. The model in brief was an integration of promotive,
preventive and curative services through a process that was democratic
decentralized and participatory; oriented to vulnerable groups, economical,
involving the people and increasing their capacity to solve their own problems. In
principle it was an endorsement of the Primary Health care approach evolving out
of grass roots experience in India particularly in the voluntary sector in that
phase - the 1970s.
In 1982, inspired by both these expert committee documents the Government enunciated a
National Health Policy which called for a review of "the entire basis and approach towards
medical and health education at all levels in terms of national needs and priorities". It
also suggested a restructuring of curricular and training programmes "to produce personnel
of various grades and competence who are professionally equipped and socially motivated
to effectively deal with day to day problems within the existing constraints". The policy
was focused on the development of Primary Health Care as a priority, and intersectoral
coordination as well as the involvement of the voluntary sector and NGOs in these efforts.
This policy was followed up with a National Education Policy for Health Sciences in
1989.
The late 1980s saw a convergence and increasing intersectoral complementarity in India's
planning efforts, especially in the linkages established in health care planning with areas
such as women's development, integrated child development, anti poverty programmes and
minimum needs programmes, water technology mission, family planning, literacy
programmes and housing programmes. National policy on education, initiatives to
promote gender equality, and more emphasis on rehabilitation of disabled, AIDS control
and newer priority problems. By the end of the 1980s all these efforts have however run
into a new obstacle caused by political changes in the country and the development of a
new economic policy as part of the global pressure on India to make structural adjust
ments and integrate with the global economy. The new primary health care focused shift
in health planning and health service development had hardly got of the ground and begun
to make headway when the larger socioeconomic and political crisis overtook the country.
The future of health care services development is now very largely linked to the direction,
emphasis and priority this broader economic policy effort will give to health and health
care issues.
48
B. Two continuing challenges
First, there is a great regional disparity in health. Development indices and data from the
last decade highlight this feature effectively. The overall population profile based on all
India rates and projections tends to mask this disparity. Health planners and policy makers
are increasingly recognizing this disparity and the whole concept of more decentralized
health planning and health policy making is seen as an urgent need. In this context a new
focus on the "BIMARU" area of India is gaining ground. (Bihar, Madhya Pradesh,
Rajasthan and Uttar Pradesh). The acronym also means ’’ill" in Hindi - reflecting the
growing concerns about the backwardness in health and social indicators of these states
when compared to the all-India data or to the more advanced/developed states of Kerala,
Tamil Nadu, Maharashtra and Punjab.
Second, urban-rural differences in all aspects of development are well-established facts
and these are not showing much improvement in spite of all the emphasis about minimum
needs. Urban areas continue to draw the major share of development efforts and when
rural areas do get some benefits and services, it is the top ten % of the rural rich who get
most of it.
This continuing differential leads to two key policy matters that need emphasis. First,
continuous monitoring of this difference in developmental effort is needed to provide some
stimulus to concerted efforts to reduce the disparity. Second, there is growing evidence
that urban models of development built primarily on an institutional, high technology
framework borrowed from the west or transplanted through neo-colonialism will have to
be discarded in favour of more low-cost, human resource developing alternatives. Health
care will be no exception.
There is also an increasing recognition that urban statistics and indicators, thourgh
definitely better than rural, also mask the growing disparity in health indicators of the
urban slum populations from the rest of their urban counterparts. This calls for a concerted
effort to obtain disaggregated statistics by social classes and other forms of classification
of marginalization so that initiatives are focussed on those who need them most - both in
rural and urban areas.
3.15. References to this chapter
A. Centre for Monitoring Indian Economy (1988)
Standard of Living of the Indian People
Economic Intelligence Service, CMIE, Bombay, Feb. 1988
B. Central Bureau of Health Intelligence (1992)
Health Information of India - 1991. CBHI,
Directorate General of Health Services, Ministry of
Health and Family Welfare, Govt, of India, Nirman Bhavan, New
Delhi
49
C. Ministry of Health and Family Welfare (1994). Annual Report 1993 - 1994
Government of India, Nirman Bhavan, New Delhi
D. Voluntary Health Association of India (1992). State of India’s Health
VHAI, New Delhi
E. Rural Health Division, DGHS (1994). Bulletin on Rural Health Statistics in India March 1994. Directorate General of Health Services, Ministry of Health and
Family Welfare, Govt, of India, Nirman Bhavan, New Delhi
F. Ministry of Health and Family Welfare (1987)
Health Manpower, Planning, Production and Management
Report of Expert Committee
G. Expert Group on Population Policy (1994)
Draft National Population Policy - submitted to Ministry
of Health and Family Welfare, Govt, of India, New Delhi
(May 21, 1994)
H. Department of Family Welfare, Govt, of India (1994)
India - Country Statement - (Cairo 1994)
(unpublished document), GOI, New Delhi
I. Centre for Monitoring Indian Economy (1994)
Standard of Living of the Indian People
CMIE, Bombay - 1994
J. Mukund Uplekar (1990). Health Information and Research in India: An overview
FRCH, Bombay, August 1990
K. Narayan, Thelma (1993)
Approaches towards better health and health care in India
(A background paper for CEBEMO annual publication)
L. Narayan, Ravi (1993)
Sustainability of Programmes in the Voluntary Sector Reflections on some questions
Action Aid Disability News, Vol. 4, No.2, 1993
M. CHC (1989)
Community Health in India
Health Action, July-August 1989
N. Narayan, Thelma (1993)
Two thousand AD & Beyond
Report of a policy Delphi; Survey on contextual and policy
level issues important for future health-related work of CHAI
CHC, Bangalore, March 1993
50
4.
DUTCH DEVELOPMENT POLICY AND INDIA
4.1. Dutch bilateral development cooperation with India
Bilateral development cooperation between the Netherlands and India on a structural
(yearly) basis started in the beginning of the sixties.16) While in the first years Dutch aid
mainly consisted of the supply of goods and financial assistance, gradually (and especially
in the eighties) development policy changed to technical assistance and project aid. While
in 1980 the share of non-project aid still amounted to 98%, in the period 1987-1992 this
percentage had decreased to 50% (DGIS, 1994). Dutch development aid to India has for a
long time been strongly influenced by commercial interests, particularly in the fields of
water transport, dredging, and fertilizer production.
In 1969, India was granted the status of priority country (countries on which Dutch
development assistance was to be concentrated). After a period of continuous growth of
the cash ceiling for the regular programme (from Dfl. 150 million in 1975 to Dfl. 234
million in 1981), after 1981 the cash ceiling stabilized around Dfl. 200 million (with
additional funds from other sources, e.g. the sector programmes).17) While in the
beginning the cash ceiling consisted entirely of Ioans, from 1975 the share of grants
gradually increased from 20% in the late seventies to 50% in later years.
Dutch development assistance to India during the 1980-1992 period (both regular and
non-regular) amounted to a total of Dfl. 3.538 million (more than 80% of which was
channeled through the regular programme). In this period, India was the country that
received the largest amount of Dutch development aid. The Netherlands was the fifth
largest bilateral donor (providing 10,5% of all bilateral aid; 5,2% of total aid) (DGIS,
1994). To put this amount within a proper perspective: on a per capita basis, the net
annual flow amounted to only Dfl. 0,25 (US$ 0,10) per year.
Activities of the CFA's in India are financed through the non-regular programme
(disbursements of which are included in the total of Dfl. 3.538 mentioned above). From
1980 until 1990, the four Dutch CFA's together received a 6% share (yearly) of the
overall development budget. In the programme financing agreement recently (1993)
concluded between the Government of the Netherlands and the CFA's, this share was
raised to 7% . As the CFA' have also access to funds from the 'special programmes' of the
category of non-regular funds, their total share in the disbursement of Dutch development
assistance is estimated to be 10% for the period 1980-1992 (DGIS, 1994).
Recently, in the light of policy changes associated with the policy document for Dutch
development cooperation ’A world of difference' (1990), a new policy plan for India
(1992-1995) had to be prepared. Some of the main points relevant as background material
to this study are summarized below. Possibly, the conclusions and recommendations of the
1994 evaluation of Dutch development assistance to India will lead to new policy changes
in the near future.
Main general point of departure for Dutch development policy is 'sustainable development'
defined as 'development which provides for the needs of the present generation without
51
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jeopardising the opportunities for future generations to provide for their needs' (DGIS,
1992). Another important policy priority is the struggle against poverty and its
socioeconomic and ecological aspects. In A World of Difference' the need is stressed to
combat poverty in a direct way.
An important policy change for development cooperation with India (and other developing
countries as well) is the decision to reduce the volume of loans for development activities.
This meant that the cash ceiling for India was reduced from an average of Dfl. 200
million per year (in the eighties) to Dfl. 160 million in 1992. As a result of this policy
change, Dutch development assistance to India now wholly consists of grants, and no
longer contributes to the increase of India's debt burden.
The policy changes described above have necessitated a gradual change in the composition
of Dutch development assistance to India, without doing damage to the continuity of
certain programmes (e.g. drinking water supply). All new activities will have to be
reassessed in the light of their expected effects on the environment (sustainability), the
position of the target group of the poorest, and the position of women (the policy priorities
of Dutch development assistance).
For reasons of efficiency and managability, from 1985-1986 Dutch project aid became in
principle limited to the states of Andhra Pradesh, Gujarat, Karnataka, Kerala, and Uttar
Pradesh (the states where most Dutch assistance had been concentrated before).18)
Further, four priority sectors were determined: rural drinking water, land and water
management, environment, and water transport. In special cases (e.g. programmes that
have relevance for India as a whole, and urban poverty programmes), exceptions to these
restrictions were possible (see DGIS, 1992).
The states mentioned above have not been selected on the basis of poverty criteria (almost
two thirds of the poorest people in India live in the states of Bihar, Orissa, West Bengal,
Assam, Madhya Pradesh, Uttar Pradesh and Rajastan; DGIS, 1994). Rather, their choice
reflects a historically grown situation. In the policy plan 1992-1995 it is stated that a
revision of this relationship based on aggregate (state-level) data about the poverty
situation is not opportune. Given the enormous local and regional diversity and the
importance of paying attention of vulnerable groups like tribals and scheduled castes,
inhabitants of slums, selection of regions is a more effective instrument than selection of
states on the basis of aggregate data on the poverty situation in those states. The five
states in which Netherlands development assistance is concentrated together cover an area
of about 1 million square kilometres, with a total number of 320 million inhabitants
(DGIS, 1994).
In the 1992-1995 policy period, 60% of the cash ceiling will be reserved for the four core
activities mentioned above (within this category, expenditure on the water transport sector
will be restricted to a maximum of 15%, while minimally 35% will be allocated to
activities in the rural development sector). The remaining 40% will be reserved for
programme aid. Within this category, the share of import support will be gradually
reduced to 15%, while 25% will be reserved for budgetary support for poverty alleviation
programmes.
52
Sectors and activities receiving special attention are rural development, land and water,
rural drinking water supply, credit facilities, non-formal education, employment, the
environment, women and development, combating urban poverty, infrastructure (water and
transport), and education and research.
4.2. General development policy of Cebemo
Cebemo (Central Agency for the Co-Financing of Development Programmes) is one of
the four co-financing agencies (CFA's) of Dutch development assistance, through which
development aid is channelled to non-governmental partners in developing countries.
Cebemo was established in 1965 at the initiative of the Central Missionary Council (CMC)
and the missionary movement in the Netherlands. Cebemo's development policy is rooted
in and draws its inspiration from its (Catholic) religious background.
Main objective of Cebemo’s development policy is the long-term (sustainable)
improvement and strengthening of the position (emancipation) of poor, deprived and
neglected groups in developing countries, allowing these groups a greater access to
knowledge, income and political influence.
Implementation of this policy takes place by giving support to the following activities:
activities of/for deprived and neglected groups at grassroots level (basic amenities
and services like education, health care, housing, water, income generation, and
group formation);
activities aimed at the strengthening of social organizations, related to activities
by/for deprived and neglected groups at grassroots level;
initiatives aimed at influencing policy, both in the Netherlands and internationally,
particularly if these are related to activities by/for deprived and neglected groups at
grassroots level (Cebemo, 1993a).
The main ('natural') partners of Cebemo are organizations of the Catholic church or related
to the church, dedicated to the improvement of the situation of the poor. But Cebemo does
not restrict itself to its 'natural partners'. For specific issues, alliance is sought with other
partners (NGO's).
Cebemo receives its funds from 3 sources:
the co-financing programme (CFP);
additional funds from the Government of the Netherlands (DGIS);
additional funds from the European Union (EU).
In 1993, the co-financing programme of the Dutch government and the four cofinancieng agencies was extended for a period of four years (1993-1997) by the
conclusion of a new co-financing agreement between the CFA's and the Government of
the Netherlands. In that year, 92% of Cebemo's total financial resources originated from
the first source (CFP).
53
Recently the decision has been taken to intensively cooperate with Vastenactie Nederland.
Further cooperation and integration is expected to materialize by the end of 1994. Further,
Cebemo and Mensen in Nood have decided to establish a common desk for emergency
aid. Cebemo will also coordinate its assistance to Eastern Europe with this organization.
Mensen in Nood, MEMISA, Vastenactie and Cebemo also intend to expand their
collaboration. Regular contacts with the other CFA’s (Hivos, Icco and Novib) are
maintained through the common forum of GOM (Gemeenschappelijk Overleg
Medefinanciering). On the basis of recommendations made in the impact study, the GOMpartners have decided to cooperate on the following issues:
the formulation/compilation of NGO-country documents;
developing instruments to stimulate cost-consciousness among the CFA’s and their
partners;
further elaboration of the concept of the concept of ’structural combat of poverty’.
Cebemo cooperates with Icco in the field of professional guidance and support of
programmes.
Internationally, Cebemo actively participates in CIDSE (Cooperation Internationale pour le
Developpement et la Solidarite). In Europe, Cebemo cooperates with euro-CIDSE, over
which Cebemo presides. Within the framework of CIDSE, Cebemo intensively cooperates
with (German) MISEREOR in particular. In the future, cooperation with like-minded
organizations in the Netherlands, Europe and the United States will receive full attention
(consortia, agreements on geographic concentration etc.).
In 1993, 1.000 commitments of more than one year were concluded for a total amount of
more than Dfl. 160 million.
Specific attention was paid to a number of special themes and issues: women in
development, sustainable land use, income improvement, human rights, indigenous people,
and the population problem.
Region
Number of projects
Commitment (Dfl.)
320
372
291
17
58.018.150
34.175.305
65.557.998
2.670.107
1.000
160.421.560
Africa
Asia
Latin America
Other projects
Total
Cebemo commitments in 1993 (source: Cebemo, 1993b)
In Asia, Cebemo supported 372 projects for a total amount of Dfl. 34.175.305 in 1993.
Most important fields of attention in 1993 were:
primary production
health care
institut. development
: 10%
: 11%
: 29%
54
education
: 17%
strengthening of
counterpart organizations: 10%
human rights
: 10%
Other important priority themes in Asia are: the combat of urban poverty; small-scale
economic and income generating projects; women and development; the environment and
strategies for sustainable development; indigenous people.
For Cebemo, India is by far the most important partner in Asia. Almost sixty percent of
the total number of Cebemo projects is located in India.
Number of
projects
Commitment
(Dfl.)
% total
India
Other Asian countries
General projects
200
156
16
15.761.097
14.942.747
3.471.461
46,1
43,7
10,2
Total
372
34.175.305
100
Location
Distribution of Cebemo commitments in Asia (source: Cebemo,
1993b)
4.3. Cebemo in India
More than half of the new commitments made in India in 1993 belong to the sectors
’institutional development’ (28,9%) and (formal and non-formal) education (25,1%). Other
important sectors are health care (12,8%) and primary production (9,9%) (Cebemo, India
1993).
As far as possible, in India Cebemo supports initiatives that are complementary to
activities of the government and non-governmental organizations. An important objective
is to create access for the target group to both governmental and non-governmental
programmes. Often the target group lacks access to these programmes, due to ignorance or
lack of political influence. Therefore,the second important policy objective is creating
awareness among the target group.
Cebemo's target group orientation is aimed at the direct combat of poverty. Special
attention is given to:
landless and marginal farmer households in the rural sector;
the urban poor;
traditional fishers and migrants from Sri Lanka;
dalits, adivasis, and backward castes;
Cebemo recognizes the special position and role of women in Indian society. This factor is
taken into account in the assessment of and decision-making of project proposals.
55
Cebemo intends to gradually shift its attention from South India to North India. Therefore,
due attention is given to the extension of its network of partners and advisory organiza
tions. Other important themes are environment and ecology, communalism, caste
discrimination, relations between the government and NGO's, labour issues, women in
development, social justice, peace and human rights, and interreligious cooperation.
Cebemo builds its partner network by stimulating the extension of regional resource
centres. Apart from these, national partners like ISI, Caritas India, CHAI and PRIA are
important partners.
4.4. Health policy of Cebemo
Cebemo currently has no policy paper specifically stating its health policy in India.
However, the 1994 position paper on basic health care in the Philippines (Cebemo, 1994)
may serve as a guideline for health policy in general. The following description of
Cebemo's health policy is based on this policy document.
For more than twenty years Cebemo has supported the concept of primary health care, and
especially its community-based health care component. More than fifteen years after
'Alma Ata' the concept retains its validity, but adaptations have become necessary. Health
policy should be able to react flexibly to important political, socioeconomic, and other
changes like the spread of AIDS, urbanization, and population growth.
When appraising a project proposal in the health sector, special consideration will be
given to the health situation of the population of the particular area in comparison with the
national average. In the light of important processes like the high pace of urbanization in
many developing countries, areas of concentration of Cebemo support might be redefined
and lead to new geographic and thematic priorities.
Priority will be given to programmes in the health sector ’which take into consideration the
existing traditional health system and promote genuine traditional medicine’ (Cebemo
1994; 12). Moreover, Cebemo gives special consideration to ’traditional lifestyle groups',
like tribal groups, who tend to occupy a marginal position in society. In general, the
appropriateness of existing approaches will have to be the object of continuous assessment,
while innovative approaches and new activities will have to be taken into consideration.
Cebemo remains committed to Primary Health Care (PHC) at the 'first' (community) level.
It is stressed that the PHC approach is a political choice for a new approach to health care
at grassroots level. Cebemo considers operationalization of PHC through its component
parts of Basic Health Services (BHS) and CBHC (Community-Based Health Care) to be
an appropriate approach towards improving the health situation of the population.
Cebemo uses the concept of Basic Health Care (BHC) to operationalize the PHC concept.
Its contents will have to be formulated in accordance with local needs in specific
situations, and consist of a number of health and health-related activities for the
improvement of health, and for prevention and promotion.
56
Within BHC, programmes which show the following characteristics will be emphasized:
qualitative rather than quantitative aspects;
integrity, stability and professional competence of the organization rather than its
size;
lasting effects on basic health care rather than quick results;
a measurable indication of a gradual improvement of the health situation of the
target population.
The main criteria for Cebemo to support health programmes are the degree to which a
community can be effectively reached, can actively participate and can benefit from the
programme. In this respect, capacities, programmes, services and activities of organizations
in the health sector rather than structures (apex organizations, support organizations,
implementing agencies) are important.
Cebemo distinguishes between the following important actors and partners in the field of
health care:
government: health care is and remains primarily a responsibility of the
government. NGO’s should not duplicate government efforts or replace them, but
have a complementary or supportive role;
health professionals: the need of ongoing training for staff working at community
level is stressed;
the Catholic church: in view of the potentially positive role of the church, its
activities for the poor in the spirit of PHC will be promoted;
NGO’s: ’’Support for NGO’s, especially those implementing the PHC concept at
grassroots level, the- BHC, will be continued. Without dismissing the role of
intermediary organisations, their added value to the NGO's working in the field
will have to be substantiated. National bodies and networks are the prime
responsibility of their members” (Cebemo, 1994; 13).
Cebemo is in favour of cooperation between the church, NGO's and the government,
provided that each retains its autonomy. Support of programmes in collaboration with the
national or local government will be given priority. A major priority is the support of
organizations working at the grassroots level, in close relationship with the target
population. The strengthening of such people's organization will be fostered.
A number of themes receive special attention in Cebemo's health policy: AIDS, industrial
health hazards, urban health problems, and increasing population pressure. It is expected
that the churches and NGO’s can play a positive role in addressing these problems, in
view of their commitment, their innovative approach, and proximity to the community.
Activities and services addressing the problems mentioned above will have to be part of a
comprehensive health programme. Activities for the prevention and control of AIDS will
be stimulated. Here, an adequate response to the threat of AIDS is needed rather than
academic and theological discussions.
Another theme that receives attention is the development of a health financing system at
community level. In this respect, NGO’s can play an important role in testing out different
possibilities for such a financing system.
57
4.5. General development policy of Icco
Icco (Inter-church Coordination Committee for Development Cooperation), one of the four
Dutch co-financing agencies (CFAs), was established in 1964 by churches and Christian
social organizations, inspired by their religious background to combat poverty and strive
for social justice and equity for the poor in developing countries.
The organization has set itself three main tasks:
1.
2.
3.
financing (non-governmental) developmental activities in developing countries and
in Middle/Eastern Europe;
providing information, both in the north and the south, about the poverty problem
and Icco's activities;
Influencing policy that has a bearing on the poverty problem, both in the north and
the south (Icco, 1993a).
Icco receives the greater part of its financial resources from the Ministry of Foreign
Affairs, Directorate General for International Cooperation (DGIS) of the Government of
the Netherlands, which channels part of its development budget through the CFAs
(Cebemo, Hivos, Icco and Novib) in the framework of the co-financing programme. Apart
from this yearly block grant, Icco receives additional funds from the Government of the
Netherlands (special programmes) and from the European Community. In 1993, Icco has
concluded new financial agreements for a total amount of Dfl. 162 million (Icco, 1993c).
Through its policy, Icco supports local and national initiatives aimed at the structural
improvement of the position of poor and marginalized groups in society. At the same time,
Icco provides information to the general public and tries to influence policy in the north,
realizing that our affluence is part of the problem of the poor in developing countries.
To use its scarce resources as effectively and efficiently as possible, Icco has to make
policy choices between countries, partners, target groups and sectors. Icco’s policy is
further elaborated in the country policy documents, which provide updated information
about the countries in which Icco cooperates with partner organizations. Icco has partner
organizations in about fifty countries.
Icco gives priority to the support of developmental initiatives at the local level. Its partner
organizations have the knowledge and provide the information necessary for Icco to base
its country policy on. In its relations with partners, Icco stresses the need to give priority
to initiatives that reach poor and marginalized groups, such as ethnic minorities, the
handicapped, and women. Priority is given to conscientization and organization, basic
social services, income generation, and rural development.
In Icco's development policy, three themes are of crucial importance: human rights,
women, and environment. These themes function as the yard stick for developmental
activities at all stages (Icco, 1993a).
Icco's contribution to health care aims at providing adequate basic health care facilities. A
central place is accorded to prevention, esssential drugs, AIDS, family planning, and peri58
natal and mother and child care. Preferably, health initiatives are part of a more
comprehensive approach to health and development.
Icco actively seeks national and internation cooperation with Protestant Christian organi
zations, but also with the other CFA's. Recently, an agreement was reached with (Catholic)
Cebemo about far-reaching cooperation between these organizations. Internationally, Icco
closely cooperates with like-minded foreign Protestant agencies, active in the field of
development. In this respect, Brot fur die Welt, Christian Aid, and Evangelische
Zentralstelle fur Entwicklungshilfe (EZE) are important international partners. All agencies
mentioned are members of the Association of Protestant Development Organizations in
Europe (APRODEV), and maintain close relations with the Geneva-based World Council
of Churches.
In 1993, Icco concluded funding agreements for a total amount of Dfl. 162.210.980. In
Category IV (the co-financing programme) 518 contracts were concluded for an amount
of Dfl. 142.154.753 (the remaining Dfl. 20.056.227 originating from the categories of
special programmes and from European Union funds). Category IV funds were divided
over the continents as follows:
Number of contracts
Total amount (Dfl.)
Africa
Asia
Latin America
Other contracts
190
118
190
20
49.673.573
42.812.208
41.283.001
8.385.971
Total
518
142.154.753
Region
Icco: category IV contracts concluded in 1993 (source: Icco,
1993c)
As can be seen from the following table, India is an important Asian partner for Icco:
Country
Number of projects
Total amount (Dfl.)
India
Philippines
Vietnam
Cambodja
Thailand
Bangladesh
Other countries and
continental programmes
42
23
6
7
8
7
10.892.673
9.499.190
4.778.326
3.910.025
2.605.058
2.483.482
25
8.643.454
Total
118
42.812.208
Icco: number of projects and contributions in 1993 for
important partner countries in Asia and the Pacific (source:
Icco, 1993c).
59
4.6.
Icco in India
Icco has recently issued its new policy profile India for the period 1993-1995 (Icco,
1993b). Icco has been active in India from 1971. In the past period a gradual shift can be
seen in Icco’s development policy in India. In the first period (1971-1975) Icco restricted
itself to material support (infrastructure, equipment) for 14 projects in the fields of health
care and education implemented by the Protestant and Orthodox churches.
From 1975, Icco’s policy shifted to the co-financing of programmes not necessarily related
to the churches. In the same year it was decided to give special attention to India, in view
of the magnitude of the poverty problem in this country, the increase of funds for the
CFA’s, and the decision to follow a target group policy.
From 1976, priority was given to community development projects. More attention was
paid to specific target-groups (poor and marginal farmers, landless, tribals, untouchables)
and their active participation. In the eighties, the contribution of supported activities to a
process of structural change became an important criterium. In addition, from 1985 Icco
systematically contributes funds for large integrated rural development projects.
The total contribution of Icco to partners in India during the period 1971-1990 amounts to
Dfl. 150 million, comprising 790 projects of 272 organizations (9% of which were
national organizations) throughout India. Total funds available per year for India
(including additional funds from the Government of the Netherland and the EC) amount to
Hfl. 14-15 million. In the period 1989-1991, total allocation to counterparts was
considerably reduced, mainly for financial reasons. After 1991, allocations to India have
increased again. Main reasons for this are the recognition of the magnitude of the poverty
problem in this country, and the availability of a large number of NGO's in India, both in
rural and urban areas (Schulpen and van der Velden, 1992).
Regional spearheads of Icco support during this period were the states of Tamil Nadu,
Andhra Pradesh and West Bengal (53% of all financing). Ther northern states of Haryana,
Punjab and Himachal Pradesh are under-represented.
The policy shift mentioned above (from construction projects to community development)
is clearly illustrated by an analysis of the types of projects supported. While construction
projects represented 87% of Icco-supported projects in 1971-75, 46% of the projects
supported in the 1986-'9O period were community development projects. A breakdown for
the period 1971-'9O shows the following distribution:
community development : 39%
12%
health care
:
9%
education and training:
5%
training
:
refugees
alternative media
emergency aid
legal aid
: 4%
: 4%
: 4%
: 1%
Target group of Icco are 'the poor'. In practice this general category consists of a great
variety of poor and marginalized groups in Indian society, like tribals (adivasi),
untouchables (harijans), and lower castes and classes. The majority (68%) of projects and
programmes supported by Icco are rural. Urban projects and programmes account for 9%,
60
while the remainder (23%) have a mixed character.
While in the first period of Icco's involvement in India (1971-’75) only Christian
organizations were supported, in the period 1975-1990 gradually the share of secular,
Gandhian, Hindu and Muslim organizations increased. At the moment, some fifty percent
of the total number of projects/programmes supported by Icco concern activities by
Christian organizations or by secular organizations with a Christian background (Icco,
1993b).
In 1989-'9O the India desk of Icco executed an internal evaluation of the relevance,
efficiency and effectiveness of Icco-supported organizations and projects. The evaluation
showed that about fifty percent of Icco-supported activities in India was efficient and
effective, for the remainder the precise effects are unclear or lacking.
4.7. Health policy of Icco in India
In the field of health and health care, Icco gives priority to the support of organizations
that advocate an integrated approach to health care, in which full attention is given to
social, economic and political factors that have an impact on the health situation.
Monosectoral approaches will no longer be supported. Icco promotes a combination of
community-based health care (CBHC) and basic health services (BHS), supported by
baseline surveys. Active participation of the target communities in planning, organization
and implementation is considered of central importance. Other points of priority are:
promotion and support of alternative health training and training institutes;
the support of organizations and networks which promote community-based health
care and/or basic health services, are innovative and/or act as political advocacy
organizations;
the financial sustainability of programmes (adequate planning and management, use
of local resources, appropriate technology, essential drugs etc.;
the position of women and girls;
sex education and information about reproduction that contribute to the
empowerment of women;
AIDS;
integrated approach to the rehabilitation of disabled people (Icco, 1993b).
61
5.
PROFILES OF ORGANIZATIONS, PROJECTS AND PROGRAMMES
FUNDED BY CEBEMO
5.1.
Introduction
According to the most recent overview Cebemo presently supports 109 projects with a
substantial health component in India, amounting to a total contribution of more than Dfl.
10 million. Total Cebemo contribution to these projects amounts to more than Dfl. 10
million (Cebemo: overview of health projects, September 1994; see Annex 1).
Out of the total number of projects and programmes supported by Cebemo, a preliminary
selection has been made by the Cebemo staff, based on the following criteria:
candidate programmes should be larger programmes (in terms of Cebemo's
commitment), and have a substantial health component (at least 25%—30%);
implementation (funding) should, in principle, have been going on for at least three
years;
they should be comprehensive projects/programmes rather than specifically
addressing one theme only;
they should be of some (potential) relevance to the current and future activities of
Cebemo in india (e.g. innovative approaches).
(a more practical criterium) geographical location of projects and programmes
chosen should make inclusion in the mission schedule feasible without taking up
too much of the relatively short time available.
On the basis of these preliminary criteria, the following organizations/programmes were
selected as possible candidates for evaluation:
1.
2.
3.
4.
5.
6.
7.
Bengal Rural Welfare Service (BRWS), Calcutta, West Bengal: Programme for
Rural Basic Health Care (5.2.)
Village Health Workers Scheme, Diocese of Berhampur, Orissa: Diocesan Training
Centre and Programme of Rural Health Workers, Jaganathpur village (5.3.)
St. Thomas Mission Society, Mandya, Karnataka: Community Based Health and
Development Programme (5.4.)
Karuna Social Service Society (KSSS), Diocese of Bijnor: Community Health
Programme (5.5.)
Peermade Development Society (PDS), Kerala, India: Integrated Health and
Development Programme (5.6.)
Trust for Reaching the Unreached (TRU), diocese of Ahmedabad, Gujarat:
Comprehensive Primary Health Care, Panch Mahals, Gujarat. Diocese of
Ahmedabad (5.7.)
Christian Council for Rural Development and Research (CCOORR), MAGR
District (Vengal), Tamil Nadu: Rural Health Training Centre and Extension of
Field Activities (5.8.)
62
5.2.
Bengal Rural Welfare Service (BRWS), Calcutta, West Bengal: Programme
for Rural Basic Health Care
Organization
: Bengal Rural Welfare Service (BRWS)
Project/programme: Programme for Rural Basic Health Care,
Calcutta.
Rural/urban
: rural and urban
Organization type: implementing and intermediary
: C317-1105(F)
File number
: three years (1992-1995)
Commitment
: total
: Dfl. 173.655
Financing
own contribution
: Dfl. 48.000
contribution Cebemo: Dfl. 125.655
The Bengal Rural Welfare Service (BRWS) is a secular voluntary organization based in
West Bengal. Area of operation of BRWS are the rural areas around the city of Calcutta
and some urban districts of this city. BRWS has been active for more than fifteen years in
the districts of south 24 Parganas, Nadia, Midnapur, Hooghly and Howrah in West Bengal.
BRWS centres are located in Garia and Patuli (two urban districts in Calcutta), and in the
villages of Balarampur, Jeadergot, Balakhali, Hogolkuria, Andharmanik and Majdia. These
centres serve a total population of 240.000 people (see below).
BRWS originates in a small group of volunteers who in 1978 took up the initiative of
providing low-cost curative health services for the rural poor through homoeopathic
clinics in Sonarpur Block of 24 Parganas district. The first centre was established at
Nanah, Howrah district, West Bengal. In the wake of the success of this first centre, a
number of others were established in the area. However, due to lack of organisatory skills,
funding, and other causes these new centres had to be closed down again.
After the districts of Hooghly and Midnapore had been hit by floods in 1978, the group
provided emergency medical care for 22.000 victims in the area. In 1980, BRWS was
formally established as an organization. Recognition and registration by the government of
West Bengal followed in 1981. In the years after, the scope of the BRWS programme
widened from a curative approach into a more ’integrated’ approach to health care. More
attention was given to the needs of the people and their active participation. Preventive
health care became increasingly important. Thus, the scope of activities of BRWS gradu
ally became much broader than curative health care alone. Activities added to the
programme were: mother and child care (ante-/post-natal), immunization, hygiene, family
planning, child care, growth monitoring (through the GOBI-programme) and preparation
of nutritious food, an economic assistance programme, training of community health
workers, pre—primary school education, and environmental and sanitation programmes. In
the BRWS approach, improvement of the health situation in the area is considered a
precondition for further development. Therefore, in BRWS programmes health has become
an entry point for other - social and economic - developmental activities. Main target
groups of these activities are women and children, the most vulnerable groups with respect
to health. Improving their health status and socioeconomic position has become the main
general objective of the programme. Some of the main health problems in the area are:
gastro-intestinal infections, respiratory diseases, gynaecological disaeses, deficiency
63
diseases, trauma or injury, eye diseases and skin diseases. BRWS is actively involved iin
the prevention of communicable diseases through its immunization programme, in
cooperation with the government.
Short term objectives of BRWS became low cost curative and preventive medical care for
the poor and socially vulnerable groups. Long term objectives comprise (apart from low
cost health care, including homoeopathy) information and education, organization of
women, creating awareness among the target population (health hazards, people's rights
etc.), and health training camps for other organizations.
BRWS gradually expanded its activities to new villages by following a step-by-step
strategy. First, BRWS provided curative and other health services in a 'new' village. Then,
around these activities a community centre was built-up. After BRWS presence and the
activities mentioned above had been accepted by the village population, health workers
started to organize balwadi (nurseries) and mahila mandal (women's groups). After a
limited period, usually when most of the target population has been immunized, the clinic
was moved to another (central) place. While from this moment group organization
(balwadi, mahila mandal) and involving local people were stressed, regular home visits at
the old centres for health purposes continued.
In the field of curative and preventive health care, priority is given to mother and child
care. Among the more general developmental activities, a central place is accorded to
organizing women in local women's organizations (mahila samiti). These organizations
participate in programmes for the improvement of hygiene and nutrition. In cooperation
with the government, programmes for family planning and vaccination are carried out.
BRWS has a solid relationship with its main target group of women from poor families in
the area covered by BRWS activities. The women's groups are involved in planning and
implementation of the programme activities.
Main target groups of the current programme are the population surrounding the health
centres run by BRWS (the direct target group) and the population covered by the activities
of 58 NGO's reached by the BRWS training unit (the indirect target group). The target
group consists mainly of Muslims and harijans that belong to the lowest income groups,
and work as agricultural labourers, day-labourers, rickshaw pullers, domestic servants etc.
The total target groups amounts to 240.000 people, both directly and indirectly reached
(by BRWS health services and services provided by other NGO personnel who
participated in the BRWS training programme). The majority of the total target group
belong to low-income families in Calcutta and the rural areas of West Bengal. Another
target group are the various categories of health workers (TBA's, VHW's, medical doctors,
and NGO staff) involved in community health work. It should be added that little is
known about the size of the direct target group of BRWS programmes. Probably this does
not exceed 10.000 people.
Through the activities organized in the training unit, a network of some ten voluntary
agencies (NGO's) in the working area of BRWS now exists. Once a year network
meetings are held, apart from smaller and informal meetings, to exchange experiences and
ideas. For workers of these NGO's BRWS provides training, information and other
support.
64
Through the training unit, the organization has also extended its services to organizations
in West Bengal and other states Bihar, Orissa and Madhya Pradesh (Bhopal; community
health workers among the victims of the Bhopal disaster). BRWS provides training for
health workers from these states.
Further, BRWS did relief work after floods and cyclones. Often, relief work by BRWS is
followed up by long-term development programmes, such as rehabilitative activities
among victim groups and preventive measures against damage caused by new calamities.
BRWS has built up a network of 100 trained local volunteers and 6 women's groups. It
has six centres (BRWS mentions ten centres in its project proposal for the last funding
period) from which various activities are initiated and monitored. All centres are run by
local volunteers. The new Garia centre in Calcutta, established with funding from Cebemo
(C317/1105C), has a referral service for the other centres. It is also the site of the BRWS
training unit, and serves as a family planning centre (in cooperation with the government)
and a clinic for TB, dentistry and eye diseases.
In phased-out areas, BRWS only provides non-financial support (guidance and other
forms of cooperation), as people in the areas concerned are supposed to be able to meet
their own needs. In these areas, trained VHW's maintain contacts between the population
of their working area and the government. The women's organizations in these areas
decide on their own priorities and plan their own programmes.
Local (village) health workers trained by BRWS and working in the target areas are paid
for their services by the target group itself, which also contributes to the running costs of
the different programmes. BRWS tries to reduce its dependence on foreign donor support
by paying much attention to the long-term self sufficiency of its programmes and gradual
reduction of donor contributions.
The core team of the organization consists of project officers (one homeopathic doctor, a
training coordinator, a doctor for mother and child care, a family lawyer and an
administrator). The core team is assisted by a team of multi-disciplinary experts, some of
which are government health personnel. Further, more than one hundred volunteers are
involved in the various programmes undertaken by BRWS.
From 1989 onward, the working area of BRWS has been divided into three zones:
Zone A: this zone covers Andharmanik, located in a remote area without health services.
First activities in this area took place under 1105D. More than 10.000 people are served
through mobile health services and local health workers.
Zone B: this zone covers Majdia, a remote village with a 3.000 population, and Patuli
(1.000 pop.). In both areas, people had access to government services, but the results ’were
unsatisfactory. Though the ICDS (Integrated Child Development Service programme) was
’
implemented, health status and immunization coverage continued to be low.
Zone C: this zone covers the old centres of Balakhali, Balarampur, Hogolkuria and
Jeadergot.
65
The main current activities of BRBS are:
’ ’i care programmes based on the GOBI/FFF programme (growth
integrated health
monitoring, oral rehydration, promotion of breast feeding, immunization, nutrition
education, and family planning);
running of a polyclinic laboratory in Garia, which serves as a referral clinic for all
centres;
a training centre in Garia, which provides training for grassroot health workers and
rural doctors, both from the BRWS staff and from the staff of other NGO's (e.g. in
1990 64 staff members from 29 NGO's participated in the training courses).
Through this training unit, BRWS has been able to extend its services to other
states;
ante-natal clinic in Julpia;
programme for the development of women: 6 mahila samitis, with a total
membership of approx. 375 women. Main activities are adult education, vocational
trianing, weekly meetings, reforestation, social awareness, cultural activities,
smokeless chullas, and sanitation;
education: three 'pre-primary' schools.
BRWS has received financial support from Cebemo since 1983 (C317/1105,B,C,D,E). The
current contribution by Cebemo concerns a continuation of ongoing activities from the last
funding period. Cebemo provides funds for health care, promotional activities for women,
education and training, and administration.
Main activities carried out in the current phase of the programme to reach the objective
described above are:
continuation of mother and child health services in the different areas, through
trained local health workers and with assistance from Government Health Centres
in order to maintain at least 80% immunization coverage;
at least 80% of the children under five years will be immunized against the six
basic killer diseases. On a yearly basis, 800 children will be vaccinated;
permanent family planning work through motivation and organization of monthly
operation camps, in which 12-15 women are sterilized (150 women per year).
Another 500 women per year are brought under the temporary family planning
programme;
antenatal care services to 200 pregnant mothers through weekly clinics (with the
help of trained gynaecologists, nurses and midwifes);
pre-primary education for approx. 90 children per year (30 children in each of the
three schools). In the schools two health camps per year and monthly mothers'
meetings will be organized (to create awareness and provide health education);
mahila samiti activities, to improve the socioeconomic condition of women in the
slums (50 new members per year, three awareness camps per year, handling of
cases related to the oppression of women, construction of smokeless chullas, loans
in the income-generating programme);
sanitation and drinking water programme, to control water-borne diseases.
Construction of about fifty low-cost latrines per year through the women's
66
organizations
provision of training and fruit saplings for the reforestation programme;
material assistance to village-based community organizations for village-level
developmental activities;
continuation of the existing training programme for village health workers and
community doctors (two 21 day training courses for village health workers, and
one course for rural medical practitioners).
In 1991 BRWS was evaluated, at the request of Cebemo, by the Gujarat-based NGO
Trust for Reaching the Unreached (TRU). Above all, the evaluation revealed some
fundamental differences of opinion, orientation and approach between the two
organizations. Some points of criticism made by the evaluators of TRU were:
A. general:
programmes are phased-out at a too early stage (after a few years);
BRWS provides selective primary health care through a limited number of vertical
programmes, e.g. GOBI/FFF
BRWS should work in a more scientific way, and should pay much more attention
to the collection of reliable statistical data, necessary for designing programmes
and monitoring their impact;
need for more systematic research, identification of patients and problems, and the
development of specific criteria for treatment and follow-up.
B. specific programmes:
inadequate adminstration of medical records in the mother and child health (MCH)
programme, especially with regard to immunization (identification of children,
calculation of actual coverage);
shortcomings of statistical record keeping in growth monitoring. Further, as protein
energy malnutrition (PEM) did not seem to be a problem in the area of the pro
gramme, it was advised to reconsider the position of growth monitoring;
family planning: TRU was very critical of the ’camp approach’ and over-emphasis
on female sterilization;
Whereever BRWS can partake in and contribute to government programmes, it tries to
cooperate with the government. Examples of cooperation with the government are the
immunization programme and activities in the field of family planning. Health services in
the Garia centre are provided at the request of the government, which lacks health
infrastructure in the area. If cooperation is not possible, BRWS looks for other NGO's or
takes the initiatives on its own.
67
5.3.
Village Health Workers Scheme, Diocese of Berhampur, Orissa: Diocesan
Training Centre and Programme of Rural Health Workers, Jaganathpur
village
Organization
: Diocese of Berhampur
Project/programme: Diocesan Training Centre and Programme of
Rural Health Workers
Rural/urban
: rural
Organization type: implementing and intermediary
: C317-1130A
File number
: three years (1990-1993)
Commitment
: total
: Dfl. 165.708
Financing
55.700
own contribution
: Dfl.
contribution Cebemo: Dfl. 110.008
The diocese of Berhampur exists as a religious-administrative unit since 1974. In 1978,
the diocese of Berhampur in Orissa was the first church organization in India to start with
a programme for primary health care. It was realized that the heavy work load for health
personnel, the many and increasing needs of the population, and the isolated position of
their villages necessitated a training programme on health and hygiene for village health
workers (especially women).
The Mobile Orientation and Training Team (MOTT) of the Indian Social Institute (ISI)
played a central role in these first experiments with primary health care. Financial support
was provided by Cebemo (K317-0917; 1979-1982), for the training of 90 women to work
as VHW's around 9 health centres (training, guidance, follow-up, and refresher courses
were provided by MOTT-ISI). Activities were continued in C317-1130R (1982-1990;
village health workers training) and C317-1130A1130A (1990-1993; extension of
activities beyond this year was caused by exchange rate developments during the funding
period).
The state of Orissa covers a total area of 155.707km2 and has a population of 32 million
(1991). It consists fore more than 60% of hills, mountains and forests. Orissa is one of the
states with the severest poverty problem and the lowest per capita incomes in India (with
Uttar Pradesh, Madhya Pradesh, Bihar, and West-Bengal). Fourty percent of its
inhabitants belong to the marginalized groups of scheduled tribes and castes (harijari).
The diocese of Berhampur comprises 20 parishes with a total area of 51.025km2, spread
over the districts of Ganjam, Koraput, Kalahandi, Gajapati, Nowrangpur, Malkangiri and
Rayagada in the southern part of the state of Orissa. The town of Berhampur is the
diocesan headquarters. It is the second biggest town in Orissa and harbours a variety of
educational institutions, including a medical college. Jaganathpur village, the location of
the training centre, is situated at a distance of 11 kilometres from Berhampur. The diocese
of Berhampur is registrated under the Societies Registration Act and has a FCRA number.
Thus, it fulfills the conditions for receiving foreign donor funds for its programme. The
programme is supported by Cebemo from 1979.
68
The diocese has a population of 7 million. Tribals and scheduled castes make up an large
part of the population (Koraput: 70%; Kalahandi: 50%, Ganjam: 60%). The majority of
the population depend for their living on agriculture. Agricultural yields are uncertain due
to climatic circumstances (erratic rainfall patterns, drought periods, floods, storms). Tribal
groups (a.o. Khonds, Sauras, Porjas, Kayas and Bondas) seek a meagre subsistence in
small fanning; members of the scheduled castes (a.o. Panos, Dorns, Reles) often work as
marginal farmers, petty hawkers, and (landless) agricultural wage labourers. A basic
socioeconomic problem is dependency on and exploitation by landowners, middlemen, and
moneylenders.
The poor sections of the population in general, and members of tribal groups and
scheduled castes in particular, have little or no access to basic facilities for health,
hygiene, sanitation and education. They live in small, isolated settlements without basic
health care facilities, and can only be reached by foot. Prevalent diseases are water-borne
and diarroeal diseases, respiratory infections, diseases related to malnutrition, and skin and
eye diseases. Literacy among the marginalized groups mentioned above is low: 15 per cent
for males, and 5 per cent for females. The needs of these groups are hardly attended to by
government institutions. Diocesan facilities in the area of health care include: 18 health
centres and 15 mobile clinics. Social facilities include training facilities, hostels and
orphanages, old people's homes, and balwadi programmes.
The main (general) objective of the diocesan programme is the improvement of health
conditions of the rural population of the diocese of Berhampur. A specific objective is to
bring about attitudinal change among the target group population, in particular women,
and to 'help them to better understand, appreciate and accept the modem concept of
health'. To reach this objective, stress is laid on health education and community health,
preventive aspects of health care, and integration with socioeconomic, political and other
aspects of village life.
’ i can be discerned. First, to provide preventive and curative
Three main points of attention
health care to the rural masses through their own people and at low costs, and thus to
enable them to take care of their own health. Second, to build up a three-tier system that
can function as a referral system providing basic health care to the rural masses (linking
up the health centres with a promotional middle level team and the level of the VHW's).
Third, (by linking the health programme to the non-formal education programme) to go
beyond health and enable the target communities to regain their self-confidence and
develop means to improve their own social, economic and contextual situation.
The direct target group of the current (training) programme are the 252 VHW's already
active and 100 new trainees in community health in Berhampur diocese. The indirect
target group is the rural population of the diocese, with special attention to the
marginalized groups of tribals and scheduled castes.
Health care has since long been a priority in the diocesan programmes. While initially a
curative approach to health care was taken, gradually the influence of new concepts,
methods and approaches became felt: community health, health education, an integrated
approach and prevention became new points of attention, next to ongoing basic curative
services.
69
One of the main assets of the approach in Berhampur was its innovative character, which
made it an example for other diocesan organizations in India. However, in the history of
this project supervision and guidance by MOTT seems to have played a crucial role. After
MOTT involvement had come to an end in the eighties, the project suffered from a lack of
follow-up support in the isolated villages, and from the paternalistic attitude of the health
staff. Frequent changes of personnel further added to the problems. As a result, completion
of the second phase of the programme (1130R) took eight years instead of the originally
planned three years.
In view of the vastness of the diocesan area, it has been subdivided into two zones for the
purpose of programme planning and implementation Each zone has its own core team
members for the training programme:
1.
2.
Ganjam/Gajapati zone, with a training centre at Mohana
Koraput/Nowrangpur/Malkangiri/Rayagada/Kalahandi zone, with a training centre
at Rayagada
(For quantitative data on the number of courses given in these two centres: see progress
report 1130A; 1992).
When support for the Diocesan Training Centre and Programme of Rural Health Workers,
Jaganathpur village (C317-1130A) started, an active network of village health workers
(VHW’s had already been built up and consolidated. A total of 252 VHW’s (40 males and
212 females) worked full-time in about 252 villages of Berhampur diocese. Every year
between forty and fifty selected rural women receive the basic training for CHW's.
Expenses for the basic training and the first three years of VHW-activity are paid by the
diocese. In this period, VHW’s receive a monthly salary of Rp.50. After three years,
VHW-activities will have to be paid by the community for which they perform health
care activities. (According to the most recent progress report of february 1993, a total of
318 Village Health Workers are attached to 15 main health centres). Bigger villages have
two CHW's, while small villages have one each.
The main functions of the VHW are:
1.
2.
3.
4.
treatment of minor illnesses, cuts, bums etc.;
referral of serious cases to one of the government or diocese health centres;
administering of preventive medicine (polio, triple antigen, BCG etc.);
main task: community health through health education;
Selection of (women) trainees takes place by the villagers in cooperation with the sister iin
charge of the nearest diocesan health centre, parish priests and village elders. Some
VHW’s are selected form tribal groups and scheduled castes. The training is built up as
follows:
1.
2.
basic training on health and hygiene (22 days);
trainees receive their medical kits for basic health care and are placed back in their
villages (mainly interior tribal areas, where no other health facilities are available),
70
3.
4.
under supervision of the sister in charge, to take care of 100 households each;
monthly mectings/reporting at the health centre (with the opportunity for guidance
and replenishment of medical kits);
After 6 months and 12 months: a fifteen days refresher and leadership course;
during a five years' period: a ten-days' refresher course (sharing experiences,
updating of knowledge, learning new techniques, solving problems etc.).
By 1990 some 700 VHW’s had been trained in the Ganjam zone. However, only 252 of
them funcioned as full-time VHW (Brief report Community Health Programme,
Berhampur). The training centre will be utilized for the following main activities:
two basic training courses a year (20 days each for twenty persons);
four refresher training courses (10 days each for tweny persons);
the monthly one-day meetings of VHW’s (2-3 meetings a month for 15-20
VHW’s);
seminars and meetings;
regional meetings in the field of health, training etc.;
trainer courses and refresher courses;
The training centre is staffed by two diocesan health coordinators assisted by competent
resource personnel, under the overall guidance of the diocesan director of social work.
At the regional/district level two core teams of three trained staff runs the training and
follow-up programmes. At the local (village) level the staff of the nearest health centre
provides monitoring and guidance to the 252 active VHW’s.
The diocese has a capable and professional health staff at the diocesan and the district
levels, consisting of nurses trained in public health, nutrition and social work. The 18
local diocesan health centres have a professional staff as well. Relationships with
government personnel and institutions exist from the beginning. District medical officers
were asked to contribute to the training programmes. Moreover, these officers provided
trainees with certificates allowing them to work as VHW’s. Vaccines and other material
medical support were given to the health centres involved in the programme by the district
medical officer.
Difficulties encountered, as mentioned in the February 1993 progress report are: the large
area of the diocese; the isolated interior location of many target villages combined with
difficult communication; the poverty, exploitation and oppression of the marginalized
groups in Berhampur diocese, which makes the collection of funds to meet running costs
very difficult; the bad functioning of government medical and health facilities
(inefficiency, insensitivity to the needs of the villagers).
Attempts in 1986 to have a participatory evaluation executed by ISI-ES failed due to
opposition from the diocese of Berhampur, as well as internal problems in ISI-ES. Later,
relations between the diocese and the ISI were broken off. Since then a working
relationship with CHAI has been built up. At the request of Cebemo, CHAI has evaluated
the programme in 1991 and 1992 (CHAI, September 1991 and July 1992). Some
important observations made in the 1991 report are:
71
sometimes there seems to be a preference for ’Christian’ villages among the sisters
working in the Ganjam zone;
sisters and diocesan authorities restrict their work to medical (curative) remedies,
'softer options'; in some activities (e.g. immunization) they tend to take over the
work that should be done by government PHC officials, instead of representing the
villagers and their claim to health care toward the authorities (the same problem
can be seen in primary education). In short: there is a general lack of critical
analysis of 'the root causes of the ills of society'.
Some of the remarks made in the 1992 report:
superficial, inefficient and ineffective implementation of the programme due to the
vastness of the area. It is recommended that the programme focuses on a limited
number of 'model' villages, and will be gradually expanded;
there is a need to collect base-line data about these core villages; to critically
reconsider the curriculum, which concentrates on diseases, symptoms, remedies and
prevention, with little attention to social analysis, conscientization etc.; to have
more trained personnel at the core team and middle levels, more planning at the
central and regional levels, and more motivation and guidance to middle level
workers (the sisters).
72
5.4.
St. Thomas Mission Society, Mandya, Karnataka:
Community-Based Health and Development Programme
Organization
: St. Thomas Mission SocietyPro ject/programme: Community-Based Health and Development
Programme
rural and (recently) urban
Rural/urban
Organization type implementing and intermediary
C317-1505(D)
File number
three years (1992-1995)
Commitment
591.589
total:Dfl.
Financing
own contribution
: Dfl. 177.400
contribution Cebemo: Dfl. 414.189
St. Thomas Mission Society (STMS), the social branch of pastoral work in the district,
started its activities in the field of health care in Mandya district in 1980. Projects were
started from six centres in different parts of Mandya district, concentrating on (curative)
health care and some economic activities, with hardly any coordination and coherence
between the project activities on the different locations.
After an evaluation of the activities of these centres it was decided that the organization
should more concentrate on community development, with health as one point of attention.
Under the guidance of a.o. CHAI (which gives guidance to the programme from 1986), in
the field of health care STMS has gradually evolved from a selective, disease oriented
approach to more comprehensive, promotion and prevention oriented approach. After
1986, activities in the six villages were integrated and gradually other activities were
added: nursery centres, education for school drop-outs, adult education, farmer extension,
leadership training, training of village health workers, mother and child care, school
health, promotion of herbal medicines people's organizations, conscientization, and income
generating activities. Financial support for this integrated programme came from Cebemo
(C317-1505B).
Mandya district is situated in the southern part of the state of Karnataka. The district
covers an area of 12.886km2. District capital is the city of Mandya, at a distance of
40kms. north of the city of Mysore, and lOOkms. southeast of the state capital of
Bangalore. According to the 1981 census, Mandya district had a population of 1.418.109
(rural: 1.198.084, urban: 220.025; scheduled castes: 182.807, scheduled tribes: 11.653),
and a population density of 286/km2. Mandya district is subdivided into 7 taluk, together
consisting of 406 panchayat. Mandya district has 10 towns and 1354 villages.
The great majority of Mandya population (90%) is economically dependent on agriculture.
Most agriculture is rainfed; less than 25% of the total agricultural area irrigated. Important
irrigated crops are paddy, sugar cane and ragi. Rainfed crops are oil seed, jowar, ragi and
others. A relatively small group of landowners have been able to profit from the the Green
Revolution and associated agricultural technology and irrigation. The socioeconomic
position of the majority of poor people dependent on agricultural wage labour, however,
has further deteriorated as a result of decreasing employment opportunities.
73
Factors like religion, caste divisions and tribal origin continue to exert a great influence on
social life and socio-economic relations in the rural areas. Caste consciousness of the
higher castes is an important factor in the process of marginalization of lower-caste
people. They are the victims of various kinds of segregation, oppression and exploitation
(e.g. by moneylenders). Main religions are Hinduism (90%) and Islam (8%). Christians
and other minority religions make up 2% of the population (STMS, 1986).
A major social problem is the low status of women in society. The female literacy rate in
rural areas is very low (less than 10% in 1986). Girls marry at an early age, usually
before the age of 17. Most marriages are arranged by the family; often great expenses are
involved for payment of the dowry. Another social problem in the area is the occurrence
of child labour and bonded labour. Main victims are the economically backward and
marginalized groups, esp. scheduled castes and tribes.
Oppressive social relations are perpetuated by the influence of traditional power structures,
with power in the hands of rich, influential, landowning, usually upper caste members of
society. Usually they exert effective control over government welfare programmes entering
village society (STMS, 1986).
Mandya city has a slum area with a population of more than 10.000 (mostly settlers).
Most of them subsist on manual labour in the city. Health conditions in these slums are
very poor. Main problems are the lack of basic services and amenities, a great diversity of
communicable diseases, and social problems like theft, drugs, alcohol etc.
The main target group of the programme are the weak and marginalized sections of
society in Mandya district, Karnataka, with special attention to women and children, and
those with a harijan (dalif) or tribal (adivasi) background. Members of scheduled castes
and tribes are usually landless, and subsist on agricultural wage labour for the landowning
elite.
Main general objective of the community-based health and development programme of
STMS is the integral development of the people in the district, or 'to create awareness
among people, enabling them to critically analyse their life situation and to explore ways
and means to help themselves for their liberation from the entaglement of
underdevelopment, from the clutches of poverty, ill health, illiteracy, unemployment,
casteism and oppression of every sort' (progress report, 1992).
Main activities developed to reach this general objective are: the establishment and
strengthening of organizations, and empowering the target group. Main areas of concern in
organization building are: the formation of youth groups (men/women) and women's
groups (mahila mandaisy, encouragement to these groups to work independently and on
their own initiative; stimulation to the target group to create new organizations and tap
government resources for amenities, services, infrastructure etc. Other important topics are:
health programmes, educational programmes, and governmental programmes (creches,
night shelter for rag pickers and street children in Mandya city, vocational training).
In developing these activities, special attention will be given to the target groups of
scheduled tribes and scheduled castes ’so they can be brought to the main stream of
74
society'. At Shikkaripura, a tribal colony, main objective has been to settle the tribal
population by providing permanent jobs.
Relatively new are the slum development programmes in Mandya city. STMS is
intensively involved in these developmental activities from 1993. Some of the
achievements:
14 slums have been identified;
50 motivation programmes have been conducted (with a total participation of 1131
people);
15 health motivation seminars have been held (for a total of 576 persons);
78 youths have received training on health and leadership;
youth organizations have been formed;
The current programme is implemented from 6 centres, each of which is staffed by two
priests and a group of religious sisters and dedicated lay persons (together forming a core
staff of 37 persons). At district level ten volunteer organizations (four of which
exclusively for women) function as umbrella organizations for a growing number of
village organizations. These district organizations are fully recognized by the government
and have a total membership of 230 persons. They are responsible for programme
implementation, in consultation with the core staff members. Members have been trained
in health promotion, infant care, leadership, mobilization, and adult education. (In the
progress report, 1992, other data on personnel involved in the Community-Based Health
and Development programme are given: 47 core team members (priests and nuns), 34 field
workers, 311 animators, and 32 nursery teachers).
In 1990, main attention was focused on consolidation of existing activities. Further, there
was a growing awareness that even greater priority should be given to scheduled castes
and tribes. From 1992, policy changes have made such a reorientation possible. During
this new period, next to continuation of the existing programme, further extension of the
programme to 4 other centres is foreseen. Extension takes place after careful research in
the areas concerned, and after regular contacts have been established with the local
population, and discussions have been held with village leaders and voluntary
organizations.
Cooperation with the government has been good during the last period. Relationships have
been further strengthened as a result of the cooperation between STMS and the
government in the 1991 literacy campaign in Mandya district, the programmes for
organization and mobilization of women, and those directed at scheduled castes and tribes.
Thus greater confidence has been built among district government personnel and
administrators as well as the general public. At the same time, voluntary organizations are
increasingly able to demand government resources for various facilities (creches, night
shelters, destitute homes, tailoring centres, vocational training programmes, youth
development programmes, educational programmes for women). The main constraint in
the relationship with government institutions is the fact that 'the government machinery is
often insensitive to the needs of the people. People are sceptic about government schemes'
(STMS, progress report, 1992).
75
Strengthening of the network of voluntary organizations (NGO's) in Mandya district is
another point of attention of STMS. Attempts at greater coordination are made at the
Taluk, district, state and national levels:
at taluk level meetings are organized for voluntary organizations operating in these
taluks (coordination, discussion, action plans);
at the district level, STMS is a member of a federation of voluntary organizations,
as well as another forum for lik-minded voluntary organizations (social change,
community health, awareness). Specific issues are addressed (alcoholism,
addictions, and environmental pollution);
at state level: collaboration with the Federation of Voluntary Organizations for
Rural Development of Karnataka (FEVORD-K), Catholic Hospital Association of
India, Karnataka Region (CHAI-K), and Community Health Cell (CHC),
Bangalore. Main activities are sharing of views and experiences, training, exposure
and exchange, evaluation;
at the national level: collaboration with like-minded organizations and individuals,
e.g. CHAI, National Health Workers Forum, LSPSS (organization for development
of traditional health care and promotion of herbal medicines). Main fields:
exchange of views, experiences, ideology, facilities, skills etc. Regular 'self
evaluation' of STMS takes place in cooperation with the community health care
team of CHAI.
Quantitative data on the programme are scarce, due to the extent of the programme, the
great diversity of activities and the adaptation to local needs and priorities. Some quantita
tive data are available for the 1989-1992(7) period: During this period more than 30.000
patients have been treated in the five village clinics. Immunization programmes have been
implemented in 90 villages, providing vaccination to about 2.000 children. In these
villages, weekly educational meetings are held. There are 34 balwadis (creches) for which
34 leaders have been trained, receiving a total of 2.000 children. In 75 villages weekly
motivational meetings were held. A leadership training was held 30 times for 1821
persons. In 1990, 50.000 volunteers were trained for adult education. Each of those
trainees have weekly educated groups of adults in 1991. In 42 centres, education is
provided to early school leavers.
A number of problems and constraints confront the various programmes of STMS. First,
there is a large turnover of core team members and a great degree of inconsistence among
field workers. Moreover, personnel are often discouraged by the lack of tangible results.
Second, people of the target groups do not seem to show great interest in educational
programmes offered by STMS: 'They, especially the target group, always ask for
something that is immediately advantageous and of economic benefit'. Other problems
recently mentioned are the negative impact of village politics and the role of village
leaders, and of communal-religious riots, as well as the insensitivity of the government to
the needs and priorities of the people.
Main objectives for the (cunent) second phase of the programme are:
awareness-building among the weaker sections of the community;
creation of political awareness among the people to enhance meaningfull
76
participation in the political process and their use of their right to self-determi
nation; thus they can easier mobilize the government apparatus for their
development;
to foster collective action;
to enhance a harmonious coexistence between various castes and groups;
greater awareness in the field of health;
promotion and strengthening of regional and district level networking of different
groups;
ensure people's participation in the process of establishing a healthy society.
These objectives are to be achieved through training programmes, coordinated action
programmes, strengthening and promotion of organizations, integral development
programmes etc. A major concern is involvement of the people's organizations among the
target group. In this period priority will be given to creation of awareness, which should
lead to organization building in the villages.
In this phase of the programme, main concern and area of activities will be 'health'.
Activities during the second phase undertaken at village level are:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
health education seminars and camps, to create health awareness among the people
(including awareness of aspects of exploitation in the existing health care system,
commercialization and mystification);
health volunteers training: training of volunteer cadre in each village, to
conscienticize the people and facilitate the process of awareness-building;
health exhibition, to create awareness about diverse aspects of health (e.g.
sanitation, hygiene, nutrition, prevention etc.);
school health programme: education of school children on health;
mother and child health programme, to create health awareness among women, and
organize them to struggle for their rights;
mental camps: to educate people on diseases, their causes and prevention;
nursery centres: an entry point to new villages; creation of awareness and interest
among parents and children
non-formal education centres: for school dropouts and illiterates;
leadership camps: for orientation and training of youths identified by STMS for
future leadership roles in the villages;
youth festivals: general goals like interaction, encouragement etc.;
exposure programmes: interaction and sharing of experiences;
Other activities and points of attention during this period are cultural troop training;
organizations and awareness building; vocational (handicraft) training and production
centres; cooperative societies (for marketing etc.); small savings and self-help; cattle and
poultry; irrigation; seed bank.
77
5.5.
Karuna Social Service Society (KSSS), Diocese of Bijnor: Community Health
Programme
: Karuna social Service society (KSSS),
Diocese of Bijnor, Garhwal, Uttar Pradesh
:
Proj ect/programme Community Health Programme
: rural
Rural/urban
Organization type : implementing and intermediary
: C317-1918
File number
: three years (1989-1992)
Commitment
: total
: Dfl. 134.178,Financing
20.025,own contribution
: Dfl.
contribution Cebemo: Dfl. 114.153,Organization
The diocese of Bijnor consists of the five districts of Western Uttar Pradesh. Of these
districts, the district of Bijnor is located in the plains; Pauri (Garhwal), Tehri, Chamoli and
Uttarkashi are located in the hills. The project area consists of the districts of Bijnor and
Pauri (Garhwal). Health conditions in the area are poor. Uttar Pradesh has a 25% infant
mortality rate. Main causes of death are birth-related diseases, diarrhoea, tetanus,
pneumonia, measles, typhoid and tuberculosis.
The district of Bijnor covers a total area of 4.852km2 and had a (1981) population of
1.925.637 people. It is a poorly developed, isolated district. Six district towns have
primary health care facilties. Main activities of these centres are curative work and a
variety of extension services to the surrounding villages (immunization, malaria control,
sanitation programmes). Main disease in the area is malaria. Other common diseases are
tuberculosis, leprosy, and childhood diseases caused by malnutrition. Diseases are mainly
caused by a combination of poverty and unhygienic living conditions.
The district of Pauri (Garhwal) covers an area of 5.440km2, with a (1981) population of
623.617. It is situated in the hills of Western Uttar Pradesh. There are four centres for
basic health care in the area. In the hilly area agricultural yields are low. Damage to the
environment due to the collection of firewood is a major problem. One of the major
diseases in the area is tuberculosis, caused by a combination of poor living conditions,
smoking, and hard work under difficult climatic circumstances.
From 1987 the diocese has implemented a programme for training and upgrading of
village animators, the Awareness Training and Motivation for Action (ATMA)
programme. Village animators are considered the catalysts of development in the villages.
By 1989, 20 village animators worked in 20 villages, under the guidance of coordinators
of the health centres. To ensure people's participation, mahila mandals (women's
organizations) are established in the villages. In each village there are village level
organizations with decision-making capacity with respect to community decisions and
people's involvement. The mahila mandals in particular are considered an important forum
for people's participation. In the project area, 12 centres have been established to
coordinate and give guidance to programme activities, each comprising 3-4 villages. The
project holder, Karuna Social Service Society has been formally registered by the
government and has a FCRA number.
78
The target group of the programme financed by CEBEMO consists of the tribal population
of 36 villages in the districts of Bijnor and Pauri (Garhwal). The majority of the target
population are seasonal agricultural labourers, depending for their daily wages on a small,
non-tribal landowning elite. Wages paid to irregular agricultural labourers are very low,
and not sufficient to meet subsistence needs. Tribals are the victims of a gradual process
of marginalization, due to the loss of control over forests and agricultural land.
The general objective of the programme is to improve the health and general living
conditions of the tribal target group. Through active participation in the community health
programme, the target group are made to realize that:
health care encompasses more than merely curative intervention, and can be
adequately provided only in the context of total human development;
the target group makes a legitimate claim to the minimally necessary health
facilities and means of development.
KSSS stresses that development should be growth from within, self-growth. Therefore, a
primary role is attributed to self-help and self-sustained programmes. The role of outside
assistance is a facilitating one: coordination, encouragement, etc.
In the approach chosen to reach the objectives mentioned above, health (especially the
preventive aspects of health, and mother and child care) functions as an entry point to
total development. Central to the approach are community development and community
decision-making, the mobilization of local resources (personnel, financial, government and
local social structures) for self-help and self-sustained programmes, and (non-formal)
education. The following main activities can be discerned:
1.
orientation and training of health teams:
training and exposure programmes for the central team, health coordinators,
and animators;
health education for mothers (through the mahila mandaisy,
care of mothers: special care during pregnancy;
care of the under-five children, including regular check-ups, nutrition and
immunization, deworming, supplementary feeding, vitamin prophylaxis, and
an integrated child development programme (in cooperation with the
government);
day care centres for children of female workers;
development programmes: socioeconomic development activities like smallscale industries, cattle rearing, poultry farming, housing (in collaboration
with a government programme), saving and loan schemes.
2.
training and courses:
orientation for the central team;
awareness and motivation for the mother and child health coordinators of
the area;
training for the village level health animators
training for ayas (child care worker);
79
training for women (economic, income-generating activities);
study on the nutritional status of the target group;
assessment and evaluation of training programmes;
follow-up training and orientation programmes for animators;
The staff consists of:
the central team (six persons: a health coordinator, non-formal education director,
director of social work, MCH coordinator, health visitor, and an extension health
worker);
12 health coordinators from each centre;
30 health animators, selected from the target villages, accepted by the villagers and
able te read and write, as well as to motivate their communities. Their main tasks:
giving regular health education classes;
organizing health care activities in the villages;
dispensing basic medicine for common diseases;
family visits, and study of the health situation;
giving non-formal education to children.
36 ayas trained in child care, to take care of the day care centres. In cooperation
with the balwadi teachers, they will monitor the under-five children;
mahila mandals'. to organize the women in the villages. Motivation of the mothers
to become active in the fields of health and general developmental activities. They
are expected to become a powerful forum for people's participation.
80
5.6.
Peermade Development Society (PDS), Kerala, India: Integrated Health and
Development Programme
: Pssrmade Davalopinont Society (PDS),
Peermade, Idukki district, Kerala
Project/programme : Integrated Health and Development Programme
Rural/urban
: rural
Organization type: implementing and intermediary
: C316-2027(B)
File number
: three years (1993-1996)
Commitment
: total
: Dfl. 240.060,Financing
own contribution
: Dfl. 22.408,contribution Cebemo: Dfl. 217.652,-
Organization
Peermade Development Society (PDS) is an intermediate Catholic organization active in
the district of Idukki in the state of Kerala. PDS is related to the Syrian diocese of
Kanjirapalli, Kerala. From 1981, PDS has been active in two taluk of Idukki district
(Udumpanchola and Peermade). Main points of attention were improvement of public
health, agricultural methods, and education of girls and women. In the course of the years,
PDS has gradually switched its activities from provision of services to the target group to
stimulating organization building and self-reliance among the target group.
Idukki district, covering an area of 5087km2, is the largest district of Kerala. At the same
time, from a developmental point of view, Idukki is one of its most backward areas. Until
recently the area was scarcely populated. However, from the fifties a process of
colonization by migrants from the lowlands of Kerala and Tamil Nadu started. In 1991,
Idukki had a total population of about 972.000.
More than eighty per cent of the district population are small farmers, agricultural workers
(wage labourers), or estate workers. Most vulnerable groups are the tribals (mostly agri
cultural wage labourers) and Tamil estate workers. Landownership is predominantly small,
between 0,25 and 2 hectares. Main crops cultivated are pepper, cardamom, coffee,
bananas, yams, cassava and other tubers. In Idukki there are hardly any industrial
activities.
The level of basic facilities for health care and education in Idukki district lies below the
average for Kerala. Important threats to food production and consumption, the general
health situation, and ecology are harmfull agricultural practices (land clearing,
deforestation), and the increasing use of fertilizer and agricultural chemicals.
From 1984, Cebemo provided financial support for a programme for community
development in twelve villages (C317-1288/1288A) and for community health care in 24
villages (C317-1200A/B; people's organization, agricultural training, grihini (girls) train
ing, income-generating activities including mobilization of government funds, and a health
programme).
In 1990, suppletion funds were provided by Cebemo awaiting a proposal for a new
integrated programme. In the new proposal this 'integrated approach’ of health and
81
community development was worked out. From 1991, both programmes in 36 villages
were combined into one 'integrated' programme, for which Cebemo support was continued
(2027A). As a result, combined attention was paid to health care and general
socioeconomic development. But a long-term vision on strengthening of local
organizations and the role of PDS was still found lacking. Therefore this funding period
was used for further dialogue with PDS, in cooperation with ISI/ES.
The current programme (2027B) is a continuation of the last mentioned programme.
Cebemo funding of the ecological programme (2241R) has been included in C317/2027B,
with a Cebemo contribution of Dfl. 60.180,-.
Target group of the current programme are the poorest segments of 36 villages in the
taluks of Udumpanchola and Peermade in Idukki district. The programme is, more
specifically, directed at the 100 poorest families in each of the 36 villages. These are
divided into 5 units, the leaders of these subgroups forming the core-group in the village.
The programme includes special activities directed at men, women, and youth. The
majority of the village population consists of tribals and harijans who make a living as
estate workers and small farmers.
In the field of health, some data on coverage of the activities of the community health
programme are given in a report on the 1990 staff development programme and
evaluation:
immunization: 95% of the children were reached (a.o. 852 BCG, 926 triple, 1035
polio, 259 TT);
nutritional education and demonstrations: executed in 24 villages; promotion led to
adoption by 1200 families;
environmental sanitation: educational and supportive programmes, leading to 153
families building sanitary latrines and 793 new users of smokeless chullah\
group meeting with discussion of vital developmental issues: 205 sessions in 24
villages (with an attendance between 70% and 80%);
health education: in all villages; 170 sessions;
detection and referral of serious cases: the need for more hospital involvement;
The general objective of the programme is integrated development and creation of a
sustainable and just society using health or other programmes as entry points. Main points
of attention are: organization of the people (through a.o. sangham, grihini and youth
organizations), improvement of hygiene and nutrition, use of indigenous medicines,
immunization, savings schemes, health insurance, self-help programmes etc.
In general, the approach taken aims at the gradual strengthening of the target group
organizations in such a way that they will be self-reliant in a 5-6 years period.
Priorities for the current period include further strengthening of the self-reliance of the
target group organizations (Paraspara Sahaya Sanghanv, ’mutual aid societies’). Further, a
survey will be held to serve as a basis for further support to these organizations in
undertaking various socioeconomic (developmental) activities. The system of primary
health care will be further elaborated, with a.o. mother & child care and vaccination of all
children under five years.
82
The main objective of organization building is gradually (in a 5-6 years period) to create
a viable organizational structure for the target groups in the 36 target villages, contributing
to the sustainablility of the work of PDS. After creation of a local structure through local
organization building, further strengthening of these organizations will have to take place.
An important forum for local decision-making is the sangham. Administratively,
sanghams consist of a general body, which has final authority and elects the executive
body (a president and secretary nominated by the president of the general body, and 5
elected members). All development-related activities are discussed in, and priorities are
decided upon by the executive body. As the groups acquire the necessary management
skills through training, they are gradually given more responsibility for managing their
own affairs without outside control and intervention.
Main objective of the community health programme is the establishment of a health care
system in 36 villages linked with 6 hospitals. In this system, Village Health Workers
(VHW) are responsible for health education and basic curative services. Hospital nurses
provide training, coordination, and more complex curative services. The community health
programme was started in 1984 in 12 villages, linked with 3 hospitals. Twelve more
villages, linked with three more hospitals, were added in 1986. Thus, the programme
became active in a total of 24 villages. In 1991, another twelve villages were added.
In the long run, the health system should be able to function independently, in close
cooperation with the target group organizations. In the objectives for the community health
development programme 1992-1993 a specific health objective mentioned is 'to check the
spread of communicable diseases, especially TB and STD's, by screening all the people in
the area. Early detection of cancer is also envisaged' (PDS, community health development
programme 1992-1993).
The main objectives of the community development programme are organization of the
people and implementation of small income-generating projects (rubber, cattle rearing, bee
keeping, improvement of agricultural techniques). Further support to these activities is
provided by activities in the field of non-formal education and a savings and credit
programme. In the long run (after 5-6 years) the programme should enable the target
group members to have access to basic needs like housing and employment.
The main objectives of the ecological programme are to develop and spread the
application of alternative ecological fanning methods in the area, incorporating useful
traditional methods used by the farmers.
Main activities in organization-building:
strengthening of the target group organizations and making them more independent
from PDS (management, decision-making, financial responsibility);
health activities: primary health care, health and hygiene, education, and
improvement of environment;
developmental activities;
ecological activities;
extension work;
83
For the health programme (primary health care, health and hygiene, education and
improvement of the environment) the following activities are foreseen for the 1991-1993
period:
completion of a socioeconomic survey of target families;
distribution of a health card to each family;
identification of individuals or groups that require special attention from
paramedicals or extension workers;
listing of children under five years to reach a 100% immunuzation rate;
organizing pre- and post-natal care for mothers;
primary health care to the families (house visits);
encouragement of home deliveries and training of those willing to assist in home
deliveries;
cultivation of essential herbs;
maintenance of kitchen gardens;
the construction of at least 10 latrines and 110 compost pits per village every year;
Specific developmental activities are:
providing basic needs to every family in the target area (employment, education,
basic health care, drinking water, housing);
further organization of sanghams and starting a programme for debt
reduction/redemption;
optimal development of available land ('Whoever owns the land should develop it
in the proper and optimum wav');
alternatives to agricultural work: self-employment schemes, small joint ventures
etc.;
non-formal and supportive education;
housing: the construction of durable houses in collaboration with government
schemes;
other vital issues: drinking water, pricing of agricultural products, roads etc.;
Activities of the ecological programme:
research and development (a.o. agricultural base-line studies, trials on crop
varieties, development of low-cost technology, assessment of soil improvement
through ecological farming, demonstration and trials);
extension work (demonstration plots, contact farmers, volunteer farmers, training);
In 1991 the programme of PDS was evaluated by ISI/ES. The changes brought about in
the area are called impressive, as shown for instance in the fields of health care,
employment and income generation, education, WID, environmental sanitation, and
resource mobilization. Positive results are reported in the attitudinal sphere: cleanliness,
cultivation of herbal plants, health consciousness, agricultural methods, initiatives of the
population towards the government, banks etc.
84
But the evaluation report stresses the fact that these achievements (which by the way can
hardly be measured or quantified due to the lack of baseline data) were the result of 7
years’ work by a large team. The evaluators have the impression that more could have
been reached under conditions of better management.
One of the points of critique emanating from the evaluation is that the groups that have
been formed seem to have above all a supportive function, with PDS continuing to take
the important decisions. Therefore, according to the evaluators, a main point of attention
should be the further strengthening of the self-reliance of the target group organizations
and of the health care programme.
ISI/ES also observed that, due to a number of causes, gradually the original objectives and
strategies of the health programme became less important, and focus shifted to a great
variety of other programmes. Activities suffered from compartmentalization, and common
goals gave way to segmentation between the programmes, each with its own targets. They
concluded: 'The original idea of evolving an alternative system of primary health care is
forgotten.... What is seen at the moment is a number of activities, without a common
thrust or common goal. Each one has its own merit. But, in their isolated fashion, they
cannot achieve the objective of creating a sustainable society' (p.13-14).
ISI/ES concluded that there was a need for a redefinition of goals, and a new strategy to
orient activities towards a common goal. It was suggested that special attention should be
paid to the following points:
assessment of the type of services required, and the type of system needed to
implement it;
the village health programme should be under the control of the village core
groups, with the hospitals as partners and not as masters;
development of a long-term plan to run the health programme without external aid
within 2-5 years;
Other important points of attention for the health programme as identified by ISI/ES are:
the need for better tools for planning, improvement and evaluation of health
programmes for the poor;
the need for a base-line survey (with data on infant mortality, maternal mortality,
male-female ratio, malnutrition, protein-caloric deficiency, sanitation and hygiene,
health awareness);
the need for monitoring and evaluation, and applying new insights in preventive
and promotive measures and approaches.
85
5.7.
Trust for Reaching the Unreached (TRU), diocese of Ahmedabad, Gujarat:
Comprehensive Primary Health Care, Panch Mahals, Gujarat. Diocese of
Ahmedabad
: Trust for Reaching the Unreached (TRU),
Vadodara (Dioc. of Ahmedabad), Gujarat
Project/programme : Comprehensive Primary Health Care in a
Tribal Area, Panch Mahals, Gujarat
Rural/urban
: rural
Organization type: implementing and intermediary
: C316-2195(A)
File number
: three years (1993-1996)
Commitment
: total
: Dfl. 304.096,Financing
own contribution
: Dfl. 11.735,contribution Cebemo: Dfl. 292.361,-
Organization
Trust for Reaching the Unreached (TRU) is a Gujarat-based secular non-governmental
organization. TRU was established in 1987 by four professionals with a long-standing
experience in rural development, and particularly in programmes for rural health care.
TRU concentrates on activities aimed at improving the health situation in Panch Mahals, a
poor, isolated and economically backward area in the eastern part of Gujarat, bordering on
Madhya Pradesh.
The majority of the inhabitants of the project area are of adivasi (tribal) origin or belong
to the 'backward classes’ (non-tribal, marginalized caste communities). Many of them
work as small farmers and landless labourers. The project area is located at a distance of
65 kilometres from Baroda, which harbours a medical college and a hospital.
The present programme has as its primary objective the training and education of Village
Health Workers (VHW's) in sixteen villages in Panch Mahal district, Gujarat. The project
area has a total population of about 30.000 people. During this funding period activities
among the original target group of 15.000 will be consolidated, while the target group will
be expanded with another 15.000 people. The target group consists for the larger part of
tribals and members of vulnerable groups in general ('backward classes').
Choice of the current project area is based on a number socio-economic and healthrelated criteria:
the majority of the population belong to the groups of tribals and 'backward
classes';
the prevalence of contagious diseases like skin diseases, leprosy, malaria,
respiratory infections (especially among children), tuberculosis, STD's, diarrhoeal
diseases and malnutrition;
high infant - and pre-school mortality rates; high protein energy malnutrition and
vitamin A deficiency (five per cent of the children under the age of five suffer
from serious malnutrition);
a low (aggregate) literacy rate of 28% (for men: 50%, for women: 18%);
the majority of the population (66%) has no regular work/income, and live under
86
the poverty line as defined by the Indian government;
the geographically isolated character of the area.
Government health facilities are few and far between (situation 1990). At Shivrajpur there
is a government primary health centre, which spends most of its time and energy on the
programme for population control. Apart from some irregular immunization activities,
preventive and promotive health services do not exist. No use is made of community
health workers or traditional birth attendants. Other important activities, like health
education, care of children under five years, control of communicable diseases, nutritional
education, women's health care, are also lacking. Private practitioners and drug stores are
concentrated in the local towns, further restricting access of the rural population to health
care.
TRU has a core staff of ten qualified medical and social workers, working under the
guidance of of three medical doctors and three qualified and experienced social workers.
Field staff consists of 30 trained VHW's/organizers, recruited from the target group and
trained by the core staff. Their main tasks are the formation of women's and youth groups,
health education, mother and child care, savings and credit programme promotion,
balwadi, promotion and stimulation of hygiene and sanitation, and non-formal education.
The activities supported by Cebcmo during this funding period are a continuation of the
previous period (C317/2195R). The main objectives of the current programme are:
a.
b.
c.
d.
e.
to improve the health status of the target group (through a combination of curative,
preventive, promotive and rehabilitative services); reduction of morbidity and
mortality (specifically directed at malnutrition of women and children);
basic epidemiological research to gain more knowledge on health problems in the
local socioeconomic and cultural context (especially: malnutrition);
networking with like-minded organizations and persons, to develop a health-forall strategy;
continuing education programmes for health personnel at various levels, appropriate
to local conditions and experiences (for both project personnel and for personnel of
member institutions of Gujarat-VHA);
to stimulate and create conditions for people's participation, so that in the long term
they will be in charge of their own health (by establishing and working with
village level groups).
i
In order to realize the objectives mentioned above, a great variety of activities are carried
out:
1.
2.
curative services at various levels (30 village health workers at village level, each
serving a group of 100 families or about 500 people; three multi-purpose workers
at mobile team level; a doctor and laboratory facilities at centre/dispensary level in
Shivrajpur);
preventive services, including health education and disease prevention (regular
health education sessions and other educational activities; a special programme for
school children; education as part of preventive programmes like (a.o.) growth
87
3.
4.
5.
6.
7.
monitoring, identification of at-risk children under five years and immunization,
women's clinics, and a training programme for traditional birth attendants);
promotive programmes concerning the health behaviour of local people
(identification of local determinants of 'positive health', promotion of positive
practices, and health education action through community organizations);
training programmes (focus group camps for women, youth, teachers, community
leaders etc.; training camps for village health workers; in-service training and
continuing education programmes for staff and health workers);
information gathering and field research (data information system; basic
epidemiological research);
community organization (formation of formal and informal groups of the target
population and their involvement in all stages of the project);
networking with other NGO's (network; resource base; link-up of the network with
Gujarat-VHA, Medico Friend circle etc.; coordination of project activities through
three units/centres in Talawadi, Shivrajpur and Waghbod; Shivrajpur, having a
dispensary and laboratory facilities, will act as the referral point and training centre
for VHW's. The Baroda office maintains relationships with the hospital and
medical college).
TRU gives priority to prevention and promotion, and to a comprehensive approach to
health care in which community participation plays an important role, without neglecting
curative aspects of health care (in 1991, 11.933 persons were treated in the three clinics
run by TRU).
In the TRU proposal for the period 1993-1996 a number of problems, experiences and
major challenges for the future period are mentioned, the most important of which are:
Most local resources are concentrated in the hands of a few regional traders, with vested
interests in the existing socioeconomic relations and little sympathy for initiatives aiming
at the improvement of the socioeconomic position of the poor. The situation of the poor
target group of TRU has even worsened during the last years. They have been hit by price
rises and inflation, and can hardly meet their subsistence needs. Under the influence of
these developments, motivation to spend time and energy on common goals has decreased,
generally leading to an absence of participation in the project activities. Increasing
seasonal migration is another threat to participation in the programmes.
Sometimes an adequate choice of village health workers is very difficult. While in
principle priority is given to the training of women, in practice they are hard to find,
especially because of the low rate of (semi)litcracy among them and the weight of
household and other tasks. Other obstacles to the functioning of women as VHW's are
their lack of mobility in the village and its surroundings (especially in the case of widely
scattered village populations). In villages with mixed caste populations, their role as VHW
is seriously hampered due to problems of acceptance among different groups.
Organizing women has also proved very difficult. They are
still subject to male domination and decision-making, and exploited. Moreover, in the
villages concerned there is no culture of women's gathering except for death and marriage
ceremonies. As women are not very mobile in the village surroundings, services related to
88
the TRU-programmes have to be delivered from house to house.
Another difficulty are expectations among the target group about the role of outside
agencies or organizations. People have become used to a culture of charity and material
incentives. There is, as a result, a very low rate of acceptance of TRU’s theory of self
help and self-support: 'This has made it extremely difficult to persuade people to
participate in a public activity without material gains. This is a major inhibitory factor to
people's organization and mass mobilization'.
I
89
5.8.
Christian Council for Rural Development and Research (CCOORR), MAGR
District (Vengal), Tamil Nadu: Rural Health Training Centre and Extension of
Field Activities
: Christian Council for Rural Development and
Research (CCOORR), MAGR District (Vengal),
Dioceses of Madras and Milapore, Tamil Nadu
Project/programme: Rural Health Training Centre and Extension
of Field Activities
Rural/urban
: rural
Organization type: implementing and intermediary
: C316-3840
File number
: three years (1994-1997)
Commitment
: total
: Dfl. 411.754,Financing
own contribution
: Dfl. 141.299,other donors
: Dfl. 131.861,contribution Cebemo: Dfl. 156.639,-
Organization
The Christian Council for Rural Development and Research (CCOORR)is a secular
organization, established in 1986 by a number of committed Christian leaders, and local
leaders from the target area. After its establishment, CCOORR became a secular
organization. The eight board members of the organization have a background in the
medical, social and educational sectors. Training staff consists of qualified medical
personnel and a social scientist. Specialized resource persons are available for additional
advice.
CCOORR has extensive experience with various approaches to health care. Initial
experiments with mobile clinics were too much concentrated on medical (curative)
intervention, while preventive and promotive aspects of health care came in the second
place. Later experiments with community health workers gave problems with selection,
training, follow-up and financial support. Now, in the approach taken in Vengal, new
directions have become visible. Characteristics of this approach are among others: a small
working area; organizing inhabitants into groups and inquiring into their needs; integration
with local practices and available skills (e.g.: TBA's); making use of locally available
people (VHW's); representation of people's organizations in the board.
Headquarters of CCOORR is at Tiruninravur, Chengalpattu, MGR district, in the state of
Tamil Nadu. The town of Tiruninranvur is located at a distance of 34 kms. west of the
state capital Madras. The training centre established during the current funding period is
located at Vengal village, 16 kilometres from Tiruninranvur.
The original target area for the programme that was started after 1986 comprises 31
villages and hamlets, with a total target population of 32.000. Direct beneficiaries among
the target population are 16.000 inhabitants of these villages (the 'old area'), some 70% of
which are socially and economically disadvantaged and have a lower caste or tribal back
ground, with little access to health care facilities. All villages are located within a distance
of eight kilometres from Tiruninranvur.
90
Main points of attention in the approach taken by CCOORR are people's organizations
(the erection of elders’, women's and youth councils) and health. By organizing the village
population in councils, a local structure is created for the planning and implementation of
programmes, according to local needs and priorities.
Health activities are based on a two-tier system of so-called ’micro centres' and 'macro
centres’. While there is one micro centre for each 150 families (1.000 persons), the macro
centre is a local headquarters provided with a small hospital.
Two priorities stand out in the CCOORR-approach to health care. The first is integration
of programme activities with the local traditional medical system. In this respect the
central role of the traditional birth attendant deserves mentioning. These birth attendants
have been scientifically trained and appointed as Village Health Worker (VHW). The
VHW is the manager of the micro centre at village level (in the VHW’s house). In the
project area there are 15 micro centres and one macro centre. From the macro centre
supervision by trained health personnel is provided to the VHW’s at micro level.
A second priority is a multisectoral approach to health development. Points of attention in
the socioeconomic field are creation of awareness through (non—formal) education,
providing know-how, training and other support to programmes for development initiated
by the micro centre councils. Socio-economic development is considered a precondition
for health development.
Through the diverse groups at micro level, a great number of socioeconomic activities
have been initiated in the fields of irrigation, agriculture, cattle rearing, adult education
(for the elders’ groups), a dairy programme for family nutrition, training and employment,
small industry, creation of awareness for leaders, community banking, child development
centres, and a library (for the women and children groups), poultry, fishery, sports and
games, mental development and community banking (for the youth groups), a goat bank,
formation and operation of a banking association, vending consumer needs (for the
handicapped).
For the health care programme, some statistical data are given in the CCOORR proposal
(1992), comparing the base-line data with the 1992 situation on a number of indicators:
base line (1989)
births (per 1.000 pop.)
deaths (per 1.000 pop.)
maternal mortality
(per 1.000 life births)
infant mortality
(per 1.000 life births)
family planning acceptor rate
91
report (1992)
28
9
18
5
3
2,5
72
10%
26
17%
Now this successfull approach used for the 'old area' has been extended to the 'new area',
with a target population of 20.000, living within a radius of 8 kilometres from Vengal.
Experiences gained in the 'old area' can be used for implementing this programme in the
'new area'. In the meantime, the old area is on the verge of attaining self-reliance. The
new area is situated at a 14 kms. distance from the 'old area', and has a predominantly
tribal population.
Target groups of the programme (Vengal) are, first, the lower and middle cadres of NGO's
working in the field of rural health care and, second, the inhabitants of the villages around
Vengal, most of which are poor, have a tribal background, and have little or no access to
basic health care facilities.
The first objective of the programme supported by Cebemo is the establishment of a
primary health care training centre in an area which until now is characterized by a very
simple health infrastructure. The training centre will primarily be used for sharing and
disseminating knowledge and experiences on primary health care by middle level and
grass root level personnel of voluntary organizations (NGO's) in South India. Such a
forum for periodical meetings will facilitate the establishment of a network of NGO's in
the region.
The second objective is the improvement of the living conditions of 20.000 people around
the training centre by primary health care outreach programmes and training.
The third objective is to provide a forum for other NGO's to periodically meet, share
experiences in rural health development and establish a network.
In the proposal, a number of 180 direct beneficiaries, and 91.500 indirect beneficiaries
after five years are mentioned. For the three-years period of Cebemo support a number of
110 direct, and 54.900 indirect beneficiaries are foreseen.
Main activities of the programme are:
building a training centre at Vengal;
establishing contact with NGO's to participate in the training programmes;
organizing training programmes in the training centre for:
village health workers (traditional birth attendants, TBA's: women who
conduct home deliveries); integration of existing practices with scientific
knowledge and skills; emphasis on the preventive and promotional aspects
of health. Each year three one month-training courses are held for 10
trainees each;
rural health extension workers (RHEW): supervisory staff of VHW's, who
operate from the macro-centres in monitoring, guidance, assistance and
advice of the VHW's; coordinating role between micro- and macro levels,
and between NGO and government apparatus. Training with a duration of
18 months.
medical technologists: "This training aims at bringing science and
92
technology to village level..." by training rural persons with ten years of
schooling in x—ray, lab., ECG recording and building up medical records for
rural hospitals; a one-year training phased in two semesters;
continuing education programme (envisaged): for ex-trainees (VHW's and
RHEW's) on a monthly basis;
establishment of 15-20 new micro centres in the villages around Vengal, with a
target population of 20.000. The macro-centre for this area is to be located in the
training centre. Micro centres will function as demonstration areas for trainees,
stimulate networking among like-minded NGO's, cooperation and sharing of
experiences.
As becomes clear from the proposal, target groups, criteria for eligibility, and level of
skills and knowledge reached through the training programmes have been formulated in
such a way as to minimize the risk of migration of trainees to urban areas or other
countries.
CCOORR is registered with the Tamil Nadu government under the Societies Registration
Act, and thus recognized as a charitable social organization entitled to receive funding
from the state government and from abroad. Central staff consists of a director, a
secretary, an accountant, a typist, an office helper and a driver. For the training
programme and community programme there are three qualified training staff members, a
community nurse two cooks and an audiovisual assistant.
This programme has been recently (1994) adopted for financial support by Cebemo.
Though Cebemo has a restrictive policy towards new requests for financial support
originating from the southern part of India, in some cases exceptions to this general rule
are made. Such exceptions are the special priority areas of women, environment, urban
poverty and rural development, as well as projects or programmes that stand out by their
innovative approach. As the CCOORR takes a comprehensive approach (participative,
multisectoral, and integrated with local practices), which is considered both successfull and
innovative, can be further spread through training programmes for lower and middle NGO
personnel, and explicitly pays attention to networking among like-minded NGO's, Cebemo
has decided to give financial support to this activity (construction of the training centre
and initial expenses of the training programme).
CCOORR makes use of and cooperates with diverse government programmes in the fields
of health and development. Relationships with the government agencies are good. The
government is very interested in the training programme, and provides part of the
necessary financial support. Within five years, running costs of the training centre are
expected to be covered by local resources (both governmental and non-governmental).
93
6.
PROFILES OF ORGANIZATIONS, PROJECTS AND PROGRAMMES
FUNDED BY ICCO
6.1.
Introduction
According to the most recent overview, Icco presently supports 45 health-related projects
and programmes in India. Out of these projects and programmes a preliminary selection
has been prepared by the Icco staff. Selection took place according to the following
criteria:
1.
2.
3.
in view of the key questions of the evaluation (see concept TOR) and the increased
support by Icco of intermediary organizations, the organizations selected should be
intermediary rather than implementing;
the organizations selected should be relatively large organizations with a
considerable health component;
they should be of some (potential) relevance to the current and future activities of
Icco in india.
On the basis of these preliminary criteria, the following organizations/programmes were
selected as possible candidates for evaluation:
1.
2.
3.
4.
5.
6.
7.
8.
Child In Need Institute (CINI), Calcutta, West Bengal: Integrated Development
Programme for the Women and Child in Need
Ashish Gram Rachna Trust/Institute of Health Management Pachod (AGRT/IHMP),
Aurangabad District, Maharashtra: consortium project
Voluntary Health Association of India (VHAI), New Delhi: programme financing
1992- 1995
Christian Medical Association of India (CMAI), New Delhi: Consortium Financing
1993- 1996
Rajasthan Voluntary Health Association (RVHA), Jaipur, Rajasthan: support to
RVHA programme 1993-1997
International Nursing Service Association (INSA), Bangalore, Karnataka: Rural
Health and Development Trainers Programme 1991-1994 (---- > March 1995)
Asian Community Health Action Network (ACHAN), Madras, Tamil Nadu:
Community-Based Action for Transformation
in Asia (proposed)
Association of Sarva Seva Farms (ASSEFA) (IN 057041)
On some of these organizations, preliminary remarks can be made (some of which are
based on data gathered from the files of the organizations concerned and on informal
discussions with Icco personnel) that are relevant for a decision on the evaluandum:
INSA has been (externally) evaluated during the period 1988-1991. INSA has planned
another external evaluation for 1994. Whether this evaluation has already been carried out
or will take place in the near future, is not clear. A possible danger of over-evaluation is
clearly present.
94
ACHAN is in some respects an 'outsider'. First, ACHAN is an all-Asia umbrella
organization, operating from Madras and Bangkok. There is a lack of clarity about the
precise value of ACHAN for the Indian health sector. This could in itself be a useful main
point of attention for the evaluation mission. Second, and related to the first remark,
ACHAN seems to have few regular contacts with other NGO's in India. Currently, a new
ACHAN proposal for the period 1994-1997 is being assessed by a consortium of EZE,
Icco and Miserior. In the profiles, ACHAN has been included under the name of its new
programme, currently under consideration of the donor consortium mentioned above.
ASSEFA is a special programme funded with DGIS funds. An evaluation by DGIS is
planned for the near future. Another reason for not including ASSEFA in the evaluandum
is the fact that it is far from representative for the kind of organizations generally
supported by Icco (ASSEFA is a real multinational, supported by 15-20 ASSEFA groups'
in different countries. It has offices in Europe, a.o. in Italy. Developmental activities are
not primarily concentrated in the field of health and health—related activities. In the light
of, especially, the first point, ASSEFA has not been included in the desk study.
95
6.2.
Child in Need Institute (CINI), Calcutta, West Bengal:
Integrated Development Programme for the Women and Child in Need (phase
ID
: Child in Need Institute (CINI), Calcutta,
West Bengal
Project/programme: Integrated Development Programme for the
Women and Child in Need (phase II)
local/regional
level
rural
urban/rural
Organization type intermediate
ZA 15493 (934319)
File number
three years (1993-1996)
Commitment
545.835,total:Dfl.
Financing
local contribution : Dfl. 93.828,other donors
: Dfl. 179.089,contribution Icco : Dfl. 272.918,-
Organization
The Child in Need Institute (CINI) is a secular organization active in the fields of health
and development. CINI was formally established in 1975. Initially, CINI was primarily
concerned with relief and welfare. Later, more comprehensive approaches to village
development were taken, resulting in the current programme. CINI has been supported by
ICCO from 1990.
CINI has been registered under the Societies Registration Act. Currently CINI has a total
staff of 183 people, the majority of which are women. The board is made up of seven
persons, with an academical and medical background. CINI has a system of decentralized
decision-making through the CINI-parliament, consisting of all project officers
responsible for the implementation of CINI programmes. Decisions of this parliament are
submitted to the Governing Body, which meets every 2-3 months. In accordance with its
objective of promoting communal harmony, CINI personnel are drawn from all sections of
society and all religious groups (Hindu, Muslim, Christian, Sikh).
In the recent past CINI claims to have achieved considerable improvements in the local
health situation (infant mortality rate, crude death rate, crude birth rate; note however that
the data given by CINI in its proposal for phase II provide an interesting general
comparison with the national averages and targets for the year 2.000 for the indicators
chosen, but do not allow for an assessment of trends in the CINI target area itself and of
the impact of intervention by CINI).
Yet, the CINI approach is not restricted to health care alone. CINI considers health as part
of overall development and an entry point for other developmental activities. In the field
of health care, priority is given to preventive and promotive rather than curative aspects.
CINI fully supports the primary health care approach, and has developed a model for
health care which is appropriate, low-cost and replicable. Emphasis is laid on participation
by mothers and family members.
Initially CINI exjperimented with decentralization of health care through mahila mandals.
96
These women's organizations carried out activities in the fields of health care, pre-school
education, income-generation for women, and girl child programmes. Later, it was
realized that, with respect to other important issues, there is a great need of broader village
involvement and representation. Therefore, CINI decided to start working through socalled 'village development forums' (VDF). This new approach is now tried out on a trial—
and-error basis. The mahila mandals play an important role in the VDFs, and continue to
do so in village development.
Main programmes implemented by the organization are: health service programmes;
community development; environmental change; training; research; publication; referral
services; consultancy work. All CINI programmes are related to health and development.
The current programme (phase II) falls under the CINI community development
programme.
The programme currently funded by Icco aims at improving the health situation of women
and children through an integrated programme in 65 villages in Bishnupur Block I and II,
and villages in different blocks of Diamond Harbour subdivision of South 24 Parganas
District, West Bengal. While during the first period the programme concentrated on health,
later attention was also paid to income-generating activities for women. The 65 villages
are located in a rural area with low accessability to nearby towns. The majority of the
population are landless and daily wage labourers, many of them illiterate, unskilled, and
belonging to a scheduled caste.
For the purpose of programme implementation and gradual phasing-out, the villages
('village units') have been subdivided into three distinct areas ('sets' A, B and C). The sets
A and B are part of the existing project area. Set C consists of villages which have not yet
received any assistance from CINI and are not (yet) served by any government agency.
Villages in this last group have requested CINI to start their programmes in the villages
concerned. In these last villages CINI implements its new approach and strategy of the
current programme. Target villages can be subdivided as follows:
set A (15 villages): in these villages the village development forum (VDF) will
probably be operative. VDF will be responsible for a population of about 25.000
people, with only minimal technical and clinical support from CINI;
set B (35 villages): in these villages CINI facilitators will phase out within the next
three years. The total population of these villages is about 51.000. Villages in this
category require more regular support;
set C (15 villages): these villages have not yet received assistance from CINI, nor
are there any government services. Here, the new CINI approach will be tried out.
I
The general objectives of the programme is to improve the prospects for better living
conditions of women and children
in the target villages. As the so-called 'Village Development Forum' will play a central
role in the programme, specific objectives are:
1.
establishing and strengthening the concept of village Development Forum (VDF) to
97
2.
3.
4.
5.
run village development activities in a sustainable manner;
identification of village problems through the VDF;
collective analysis of and reflection on existing problems;
implementation of the collective solution to the problems identified above in an
appropriate manner;
facilitation of this process by CINI-personnel.
Specific activities to reach these general objectives are:
1.
field-based activities: CINI’s involvement should enable the village communities to
better identify their needs. This should allow them to target their activities. CINI
does not concentrate on health only; the major thrust of its activities will be on
general developmental issues. Health activities in the field will be carried out either
through home visits or in mahila mandal/N'DY centre or camp:
children (0-6): preventive, promotive and curative activities;
mothers: antenatal services; health and nutrition education; post-natal care;
motivation for family-spacing; referral services to the institution-based
activities;
2.
institution-based activities: emergency ward; nutritional rehabilitation centre;
thursday clinic; daily OPD;
3.
support services: support on a regular basis to the areas A, B and C in the fields of
health care, public awareness and income-generating activities from the monitoring
team For technical and clinical support institution-based referral services, training
and exposure will provided:
training exposure for trainees from government and non-govemment
organizations;
action research programme for further programme development;
clinical services;
referral centre for child care;
in-service training for CINI personnel;
family spacing programme.
Other support services which should facilitate the integrated character of the programme
are:
public awareness team
women credit groups
girl child programme
regular monitoring team
The target group of the programme comprise the women, and children under the age of six
years in 65 village units. The target group totals around 106.000 people. The major part of
programme activities are carried out by the members of the target group (community
98
members, women's organizations and the village development forum). The existence of
these groups at village level are expected to ensure sustainability of the benefits of the
CINI programme.
The distinction between three areas of target villages (areas A, B and C; see above) is
reflected in a differentiation between activities and health care objectives for each of these
areas.
Activities:
Set A: -
Set B: -
Set C: -
encouraging the process that has already been initiated to establish VDFs;
formalizing the formation of five VDF’s in the first year, and ten in
the second year;
follow-up of the evolving VDF’s in the third year;
strengthening the well-established and the newly-formed women's groups;
initiating the formation of VDF’s;
formalizing at least twenty VDF’s by the end of the third year;
identifying local group leaders;
initiating the process of community organization (mahila mandal,
VDF, etc.);
formalizing the formation of fifteen VDF’s by the end of the third
year.
Health care objectives:
Set A: Set B: Set C: -
sustaining and improving the current levels of health and nutrition achieved
in CINI’s target population in the last three years;
sustaining and improving the current levels of health and nutrition achieved
in CINI’s target population in the last three years;
improving the nutritional and health status of children under five years in
communities served by women's groups/VDF's;
increasing the knowledge and improving health related practices
among members of communities served by these groups;
increasing the acceptance of home and community sanitation;
providing family planning education and services to eligible couples
(esp. spacing);
increasing the total number of trained personnel in the community;
To monitor and maintain the quality of CINI activities, the following instruments have
been developed:
1.
2.
3.
keeping and following-up reports, proceedings of meetings and survey results of
the monitoring team;
early identification of gaps and shortcomings in the programme, and the
implementation of appropriate modifications;
the formation of subgroups of CINI personnel from various levels, to debate and
decide on developmental plans and strategies;
99
At the local level CINI collaborates with the state government and participates in the
government programme for Development of Women and Children in Rural Areas
(DWCRA). In the eastern part of India (e.g. in Bihar) in general, and West Bengal in
particular, CINI cooperates with a great number of (smaller) NGO's active in the field of
community health and development. Among the larger NGO's, CINI is an active member
of the West Bengal Voluntary Health Association (WBVHA). CINI has been one of the
driving forces behind the recent establishment of the Voluntary Action Network India
(VANI), New Delhi.
100
6.3.
Ashish Gram Rachna Trust/Institute of Health Management Pachod
(AGRT/IHMP), Pachod, Maharashtra: consortium project
: Ashish Gram Rachna Trust/Institute of
Health Management Pachod (AGRT/IHMP),
Aurangabad District, Maharashtra
Project/programme: consortium project AGRT/IHMP
: national (through the training component)
level
: rural
urban/rural
Organization type: intermediate (service and support)
: IN 074051 (933068)
File number
: three years (1993-1996)
Commitment
: Dfl. 1.724.511,: total
Financing
:
Dfl. 1.149.674,other donors
316.160,:
Dfl.
Icco (EC funds)
258.677,Dfl.
Icco (Dutch gov’t):
Organization
The Ashish Gram Rachna Trust (AGRT) in Aurangabad District, Maharashtra is a secular
organization that was established in 1977. It has been formally registered under the
Bombay Public Trusts Act in 1979, and possesses a FCRA number. During the first years
of its existence, the organization concentrated on hospital—based activities (in an old
mission hospital) and the development of a programme for basic health care in the rural
area around Pachod. In the eighties, other (more general) developmental activities were
added to the original health care programme: biogas, reforestation, safe water supply. In
1986, AGRT established a training institute, the Institute of Health Management Pachod
(IHMP). Here, training for staff of other NGO’s active in the field of basic health care are
organized.
AGRT used its health programme to systematically try out alternative methods and
strategies for basic health care. As a result of testing and research by IHMP, new insights
were developed and applied in the programme. These new insights also form the basis of,
among others, the training programme on health management.
In 1991 AGRT was invited by the Government of Maharashtra to test on a larger scale (at
the taluk level) a number of government programmes: the drinking water programme
(SOW), the health and sanitation education programme, the child health programme
(ICDS), and a primary health care programme (PHCP). The target area for these
experiments on macro-level, Paithan Taluka, has been chosen because it is a droughtprone region with poor health care services. The majority of its population consists of
landless labourers and small subsistence farmers.
AGRT stresses that, due to misallocation of scarce resources, poor social targetting and
lack of participation, the health programmes of the Indian Government have only little
effect on the health situation of the poorest and most needy groups. NGO’s, on the Other
hand, have not very successfully responded to this situation. According to the analysis
made by AGRT, their activities are usually based on anecdotal evidence or emotive appeal
rather than on analysis and empirical research. In the few cases that they were successful,
they had little impact on government or NGO’s.
101
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documentation
UNIT
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Therefore, the general objective of AGRT is to improve the primary health care
programmes and health-related programmes of the government and NGO's through:
1.
2.
3.
4.
5.
6.
the provision of health facilities;
micro-experiments with alternative strategies to implement health and healthrelated development programmes;
research;
sharing innovative experiences and research findings with other NGO's through
training programmes;
upscaling of innovative systems and strategies to the taluk or district level;
influencing the policies of, and networking with other NGO's.
Currently, the main activities of AGRT/IHMP are, in short:
1.
2.
research on and testing of new methods, approaches and strategies with respect to
basic health care in the target area;
transmitting these new methods and strategies through the organization of training
courses and through consultancy assignments.
As the old organizational structure, centreed round the hospital and the CHDP, did no
longer fit the recent developments in AGRT/IHMP, IHMP has recently become the core of
the organization, stressing the fact that research and training are gradually replacing
implementation of community health care programmes as its core activities.
From 1993, responsibility for the organization rests with the Board of Trustees, which
consists of seven people (five of which are women). The organization is headed by a
director and an associate director. Different projects are headed by coordinators, under
which resort supervisors, support staff and fieldworkers. The total personnel of AGRT
consists of 147 people, a large part of which are women (also in higher functions).
Since 1988, at the request of Christian Aid and Oxfam, Icco has funded the AGRT/IHMP
training programme and the Community Health and Development Programme in 52
villages (AZ 4378/88, 1988-1989, partyly with EC-funds; AZ 903314, 1990-1991; AZ
903079, 1990-1992 ). In 1991, Icco has contributed to the training costs of IHMP
personnel (913298).
During this funding period Icco contributes to the running costs of the current programme.
As has been decided during two consortium meetings in 1992, this programme is funded
by a donor consortium, in which Icco cooperates with CA (Christian Aid) and EZE
(Evangelische Zentralstellung fur Entwicklungshilfe). Instead of funding specific projects,
each of these three organizations finances one third of the total consortium budget. Icco
support is composed of funds from the Government of the Netherlands (45%) and from
the EEC (55%).
Apart from the activities carried out under the consortium programma, the following
donor-funded projects are being implemented: a Mother and Child Care programme
funded by WHO; a research programme by IHMP, funded by Ford Foundation; CA funds
102
the safe drinking water programme; CAPART finances tubewells and pumps. The hospital
(run by AGRT) with 40 beds is self-supporting.
Expansion of AGRT/IHMP took place from 1991 as a result of the request by the
Government of Maharashtra to participate in testing out the government programmes
mentioned above. These new developments have led to new forms of cooperation between
the donors of AGRT/IHMP, resulting in the consortium agreement in which Icco takes
part.
Target area and target group of the current programme are:
a.
b.
c.
d.
the primary health care programme of AGRT serves a population of about 250.000
people in 186 villages in Paithan Taluka in Aurangabad district;
the trainees from IHMP, who mainly work in the NGO-sector. There are two
major courses, one for senior level health managers, and the other for health
supervisors who have a minimum educational qualification (SSC) and at least one
year experience;
the Information, Education and Communication programme: 1000 schoolchildren,
250 teachers and 225 kindergarten teachers will be trained;
the safe drinking water programme: the inhabitants of about 700 villages in the
Aurangabad district will benefit from this programme.
Most of the beneficiaries are involved in the project at the implementation- and
monitoring stage. Comments of the beneficiaries, made during evaluations, are used as a
base for future project design. Women are activily involved in project activities. AGRT
makes a gender analysis, and some of its activities are especially directed to women.
Main activities carried out during the funding period are:
1.
2.
3.
4.
Institute of Health Management Pachod (IHMP) training programme:
a.
senior level health management course (7 weeks);
b.
health supervisors course (1 month);
Information, Education and Communication project (IEC): upscaling of the
nutrition programme to 186 villages of Paithan Taluka; upscaling of water
awareness camps; formation of women's groups for the maintenance of
watersources; upscaling of schoolchildren programme to all Paithan Taluka
villages.
Safe Drinking Water programme (SDW): improved maintenance programme of
handpumps, education on waste water management, sanitation and afforestation
programmes (in cooperation with UNICEF and the Maharashtra government).
During this period a further refinement of the model and further training of
government and NGO personnel in the 10 districts of Maharashtra where the World
Bank-sponsored programme is implemented, are foreseen.
Innovative Integrated Child Development Scheme (ICDS): AGRT has found out
that, while most of the malnourished children are under 4 years, 80% of the food
supplies under the government ICDS goes to children between 3 and 6 years old.
103
5.
6.
Girls suffer three times more from malnutrition than boys, but only 50% of the
food supplies goes to girls. Therefore, AGRT has developed an alternative scheme,
with attention to: training of VHW's in nutrition and growth monitoring; emphasis
on prevention of diarrhoea and infections; a better monitoring of food supply to
malnourished children; and better social targetting for children under four years and
girls. During the current period, the new method will be tried out at macro (taluk)
level by training government personnel. AGRT will provide supervision and
training, while the government will remain responsible for implementation.
Sanitation programme: a pilot programme for ten community latrines combined
with a biogas programme.
Primary Health Care programme (PHC): maternal health care, child health care, TB
control, family planning, health education and school health. The programme will
be carried out in the entire Taluka (40 'old' CHDP villages, and 146 ’new' villages
where health workers and TBA's will be trained).
104
6.4.
Voluntary Health Association of India (VHAI), New Delhi: programme
financing 1992-1995
: Voluntary Health Association of India
(VHAI), New Delhi
Project/programme: programme financing 1992-1995
level
: national
urban/rural
: urban and rural
Organization type: intermediairy (service and support)
: IN 123041 (923350)
File number
: three years (1992-1995)
Commitment
: Dfl. 2.691.597,: total
Financing
479.520,: Dfl.
own contribution
: Dfl. 1.883.577,private contrib.
328.500,contribution Icco : Dfl.
Organization
VHAI (Voluntary Health Association of India) is a national, secular non-profit nongovernmental organization. VHAI was established in 1969, at the initiative of the medical
commission of the World Council of Churches. Its establishment was a response to the
need for the promotion of community health as an alternative to the existing curative,
hospital-based and expensive health system. Most important general objectives of VHAI
are promotion of health care in India, with special attention to the poorest groups in
society. VHAI stresses the interconnection of health issues with socioeconomic and poli
tical factors. The organization tries to reach its objectives and influence health policy
through active lobbying activities (government, parliament).
Since its establishment, VHAI has become one of the largest and most important national
support/umbrella organizations active in the field of health in India. VHAI has now more
than 3.000 member organizations. VHAI has 83 staff members and four consultants. The
organization has recently embarked on a process of decentralization by stimulating the
establishment of state-VHA's and strengthening these organizations at state level. StateVHA's have been established in 19 states. Recognizing the importance of further growth at
the level of the state-VHA, from 1991, VHAI has consolidated its position and given
priority to the expansion of state-VHA's.
VHAI has a 'general body' which consists of 19 VHA-representatives. Board members
should be women for at least 30 percent, and should also be composed of people with
different religious and professional backgrounds. Changes in the composition of the board
take place every two years, while the maximal duration of board membership is four
years. The 'executive board' has 11 members. VHAI is registrated under the 'Societies
Registration Act' and has a FCRA-number, which makes it possible for VHAI to receive
funding from foreign donors. VHAI is known to be a stable organization with a clearly
outlined and consistent policy.
A major general aim of VHAI is the promotion of social justice in access to and the
provision of health care. In order to reach that goal, health issues are analysed in the
context of socioeconomic and political issues that have an impact on the health situation.
The following major objectives can be discerned:
105
creating the conditions for building up a people’s health movement through
networking, lobbying, campaigning and activities related to public affairs;
assisting in the development of low cost, appropriate and people-oriented health
programmes in harmony with locally available knowledge and skills;
providing support services to community health programmes of members and
associate organizations;
research of various aspects of primary health care.
The short-term objectives are to plan and implement a wide range of programmes and
activities, and to create an adequate decentralized organizational structure which are
instrumental to reach the long-term objectives. Specific aims for the cunent period (19921995) are:
to develop a more broadly-based health movement in the country through active
state-VHA's and their expanded memberships, particularly in the neediest parts of
the country;
to develop and further strengthen the support function in VHAI, to ensure that
members and associate organizations receive prompt and appropriate training and
information;
to build up a strong research base on important health and health-related issues
like nutrition, clean and safe environment, education, health care systems and
services, health research, and AIDS;
more systematic public education on major health issues and effective campaigning
and lobbying on these issues with the policy-making bodies;
to build up active links with similar apex bodies in health care in India, South
Asia, and Southeast Asia, and with PHC resource centres throughout the world;
to make systematic efforts towards self-sufficiency through local fund-raising and
more widespread distribution of VHAI publications.
The target group of VHAI consists in the first place of those people who have no
sufficient access to basic health care facilities, especially poor and marginalized groups in
society. It should be stressed that these can only be reached indirectly, because VHAI is
not an implementing organization. Direct target group(s) of VHAI are those institutions,
officials, NGO staff members and health workers reached by training, information,
lobbying and other VHAI activities.
VHAI is organizationally subdivided into the following departments, created to carry out
the activities mentioned above:
1. Promotion of Community Health
Main task of this department is to build up and strengthen the professional and managerial
skills in health programmes based on the principles of community health and development.
Training programmes should be need-based and participatory. The programme covers
health functionaries at different levels.
The following programmes can be discerned: a school health programme; traditional
systems of medicine; health orientation for development groups; child to child
programmes; diploma course in community health planning and management (DCHM);
106
training of trainers; correspondence course in community health and management; training
programmes on special request; publication of newsletters; preparation of training modules
and educational materials.
2. Public Policy
Main objective of this department is 'to create awareness on health policy programmes and
issues related to social justice in health care. It also tries to mobilise people's opinions and
activities with a view to influence policies and legislations at different levels so that right,
power and basic amenities can be assured to the poorest of the poor.' Related objectives
are:
creating awareness among the people, professionals and policy makers with a view
to influence policies related to health;
network development among organizations and activists with similar objectives;
activating and involving health personnel and academic circles in health-related
issues;
advocacy, lobbying, networking ang campaigning activities at different levels;
Main issues taken up are: rational drug use and drug policy; women and health; rational
use of drugs (traditional systems of medicine) and rational TSM policy; prevention and
control of AIDS (Currently VHAI is implementing a three-year project for prevention and
control of AIDS in the states of Manipur and Tamil Nadu, started in 1991-1992 and
funded by the Ford foundation); national health programmes (e.g. iodine deficiency,
diarrhoeal disease control, TB control, malaria, kala azar; pesticides; addictions.
Activities undertaken for these issues are: collection and compilation of policy documents
and scientific papers from diverse sources; analysis of the collected information;
preparation of basic material; dissemination of information to organizations and personnel
active in the field; workshops, seminars, training programmes etc.; meetings and group
discussions to facilitate networking among like-minded organizations; advocacy and
lobbying at different levels.
3. Communications
Main points of attention in the field of health education are the provision of information
material on health and health-related issues. Of particular importance is the provision of
low-cost materials accessible to voluntary groups in India (e.g. flip charts, flash cards,
books and posters in Hindi, English and other Indian languages).
The department provides support to VHAI programmes (educational material for target
groups in urban and rural setting: policy makers, the general public, middle level workers,
village health workers, school children etc.)
107
4. Information and Documentation
This department provides information support to VHAI-programmes and staff, state-VHA
members and affiliated groups, and serves as a referral centre for other users from ’outside’
the VHAI network. Priority themes are, among others, communal issues, health finance,
alcoholism, violence and health.
5. State VHA’s
The network of 19 state VHA’s which VHAI has built up forms an important instrument
for linking-up with voluntary organizations active in the field of health care throughout
India (totalling some 3.000 organizations now). The State VHA Unit has the following
functions:
1.
2.
3.
4.
5.
6.
7.
liaison with and support to all State VHA’s (staff orientation and training; planning
and implementation of programmes; relations with funding agencies, government
and non-government forums; and diverse other activities);
contacts with NGO's that are not (yet) members of State VHA’s, motivating them
to join;
contacts with union and state governments, and seeking their cooperation;
getting together VO’s in those states where State VHA’s do not yet exist;
common action programmes;
identification and development of new relevant concepts;
personnel motivation and placement, as well as receiving inputs from experienced
personnel.
Recently VHAI has prepared and issued1 an extensive report on the health situation, the
existing health system and health services in India, with special attention to sociocultural
and socioeconomic determinants of the health status of the population (VHAI, 1992). In
1991-1992 VHAI has been (internally) evaluated. The evaluation committee has made a
number of recommendations to make VHAI a more effective and efficient organization
able to face the many challenges as identified in the report ’State of India's Health’.
While until recently the relationship between the government and VHAI was characterized
by some government distrust regarding the objectives and activities of VHAI, during the
last few years this relationship has much improved. The government now fully recognizes
the important role that VHAI plays in the health sector, to such an extent that VHAI has
produced the health care section of the eighth five-year plan of the Government of India.
Icco has a funding relationship with VHAI since 1983. From 1987 support was
concentrated on the VHAI/PEHA (Public Education and Health Action) programme for
health campaigns, research on health issues, and production of information materials. At
the request of VHAI, in 1991 Icco shifted its policy of project/department financing to
programme financing. From 1992, Icco—funding takes place through a consortium.
Icco provides funding not only to VHAI, but to a number of state VHA’s as well (e.g.
Rajasthan VHA; see this chapter).
108
For Icco, VHAI is an important partner for a number of reasons:
VHAI has a network of which many regional and local NGO’s are part;
it is an important resource organization for Indian NGO’s (information, expertise,
statistical material);
it is a large producer of material for information, training and conscientization (a.o.
for NGO’s in the health sector);
VHAI implements many programmes and activities in the field of public health and
equity in health care;
because of their lobbying activities towards the government and critical appraisal of
government policies;
as an advisor to Icco.
Apart from Icco, VHAI receives contributions from other donors (EZE, Brot fur die Welt,
Christian Aid and other donor organizations). But the organization itself makes a
considerable financial contribution gained by its publications section. In the near future
VHAI's own contribution could possibly be further enlarged through! the collection of
’service fees’ from government sectors and NGO’s (and possible also MFO’s) to which
special services (consultancies, data collection, publications etc.) have been delivered. In
the future, large NGO’s like VHAI can be expected to receive increasing amounts of
funding, both from the Indian government and from national and international donors.
An important future policy issue for Icco is the reconsideration of its relationship with
VHAI in the light of the growing importance and more intensive contacts and funding
relationship with the state-VHA's. The relationship between the national and state
organizations will remain an important issue for VHAI as well.
109
6.5.
Christian Medical Association of India (CMAI), New Delhi: consortium
financing 1993-1996
Organization
: Christian Medical Association of India
(CMAI), New Delhi
Project/programme: Consortium Financing 1993-1996
level
: national
urban/rural
: urban and rural
Organization type: intermediairy (service and support)
: IN 142021 (934062)
File number
:
three years (1993-1996)
Commitment
: Dfl. 3.788.567,Financing
: total
: Dfl.
792.665,own contribution
: Dfl. 2.070.900,other donors
406.699,other local contr. : Dfl.
518.303,contribution Icco : Dfl.
CMAI is a Christian (Protestant) intermediary (support, networking) organization. It was
established in 1905 as an organization for Christian doctors (which did not allow Indian
members). CMAI has been registered and formally recognized for more than eighty years,
and during this period has functioned as the umbrella organization in the field of health
care for the Protestant churches in India. It has a membership of more than 300 institutes
for health care and some 3.000 individual members, like medical specialists and other
health personnel. CMAI is the official health care organization of the National Council of
Churches in India (NCCI).
CMAI is a national organization with field secretaries in 11 states all over the country. A
large part of its membership, however, is concentrated in the southern states of India.
Recently, CMAI has recognized that, in order remain true to its own priorities, objectives,
and Christian inspiration, it should give special attention to the BIMAROU states (Bihar,
Madya Pradesh, Rajasthan, Orissa en Uttar Pradesh). About 45% of the population of
India is concentrated in these states, where according to health -, socioeconomic
and
welfare indicators the poverty situation is most acute. These mainly Hindi-speaking states
have large tribal populations, the social status of women is very low, and feudal practices
are still common. Therefore, CMAI has decided gradually to shift attention from the south
to these northern areas. CMAI headquarters have already been moved from Nagpur to
New Delhi.
Cooperation between Icco and CMAI dates from 1979, and focused on programmes in the
fields of family planning, mother and child care, and infrastructural support when recently
CMAI moved its headquarters from Nagpur to New Delhi. In 1991 it was decided that
from 1993 onwards the majority of CMAI's activities will be financed within the
framework of a consortium. During the 1993-1996 period Icco supports CMAI through a
consortium agreement for the first time. The consortium is made up of eight donors
(among which: Brot fur die Welt, Christian Aid and EZE).
Apart from its funding relationship with the consortium mentioned above, CMAI maintains
(bilateral) relations with the World Health Organization (WHO) and the American organi110
zation Lutheran World Relief (concerning AIDS prevention and starting a programme for
field hospitals/basic health centres after the 'Jamkhed model').
According to the analysis made by CMAI of the Indian health care system and contribu
tions made to it by the church, the Indian health situation can be characterized by the
following main problems:
high mortality and morbidity rates among children, usually caused by preventable
diseases;
a severe lack of attention to the health situation of women; many women die in
childbirth;
little attention is paid to the relationship between environmental factors, poverty, a
low rate of literacy and the health situation;
health services, when available, are predominantly curative-oriented, hospitalbiased and too much stressing the role of medical doctors. Another problem is the
low quality of planning;
the factors mentioned above are further reinforced by the increasing population
pressure;
new problems with a clearly social dimension like alcohol and drug addiction,
AIDS, and negative effects of the gradual individualization of Indian society;
the lack of attention paid to the above-mentioned problems in educational curricula
for doctors and nurses, and the lack of motivation among health personnel to work
in rural areas.
According to CMAI, the church response to these problems has in the past proved to be
inadequate. This is due mainly to a lack of vision, a lack of motivated staff, conflicts
between churches and institutes, a lack of (updated) knowledge of the basic causes of
disease, weak leadership and bad management, inadequate systems for supervision and
control, out-of-date infrastructure and financial problems of many institutes, as well as to
a lack of vision on the role that the church and its institutes should play in a more holistic
approach to health care.
CMAI intends to play an active role in the process of transformation necessary to tackle
the problems described above. Moreover, CMAI stresses the need for paying more
attention to preventive and basic health care, which have until recently been undervalued.
In this way, health care should become more accessible to the poor.
In this respect, the strong religious affiliation of CMAI is not always an assett. Especially
in the case of issues that are not acceptable to the conservative segments of CMAI
membership (e.g. the socially isolated and oppressed position of women; family planning;
AIDS), wide differences of opinion may arise among the membership about the question
whether, or how CMAI should tackle these issues.
The general long-term objective of CMAI is ’to serve the Church in India so as to equip,
assist and encourage it in its ministry of healing, health and wholeness focused on the
prevention and relief of human suffering irrespective of caste, creed, community, religion
and economic status'. This general objective can be operationalized as follows:
Ill
promoting the better functioning of Christian institutes for health care in India, and
improvement of health care in general;
making India's health care more accessible for the poor groups in Indian society;
introducing, whereever possible, preventive health care and basic health care into
existing, usually curative-oriented Christian institutes for health care;
advising on how to improve the services of existing institutes for health care, and
how to make/keep them cost-effective;
Main short-term objectives are:
the promotion and spread of knowledge of the factors governing the health
situation;
the coordination of activities for the training of doctors, nurses, paramedics and
others involved in the ministry of healing (human resource development);
the implementation of schemes for comprehensive health care, family planning and
community welfare.
In implementing its policy, CMAI concentrates on a number of fields of activity:
community health (training, advise and support to community programmes);
human resources development (some 1.000 formal courses per year, for a variety of
health personnel like doctors, nurses, paramedics, laboratory workers, VHW's,
DAI's etc.). A new activity is CAMS a three-years postgraduate training on
management, leadership, and health work in the setting of rural hospitals with good
community health programmes. Cooperation exists with other centres like Rusha
and Pachod;
regional and membership development (to promote membership and stimulate
commitment of local churches to CMAI;
communications, advocacy and networking (especially in the fields of healing
ministry, health and development, women, community health, and drug abuse);
administration.
Recently, CMAI has become very active in the field of AIDS prevention. As mentioned
above, CMAI has concluded an agreement with WHO, NORAD and the Government of
India for training 1.200-1.500 doctors in HIV control and AIDS prevention within one
year. In its general AIDS policy, CMAI will focus on the following issues:
establishing safe blood banks;
developing protocols in hospitals for controlling HIV infection caused by hospital
work;
the combat of drug abuse in northeast India;
information and education;
a condoms 'undercover' programme (the spreading of condoms as part of the family
planning programme);
112
Target groups for the activities of CMAI arc the following:
the members of the association (300 institutions and 3.000 individual members);
main point of entry for this group is capacity building;
the churches (as far as their health-related activities are concerned);
in collaboration with other health networks (c.g. CHAI, VHAI) CMAI tries to
influence health professionals, the central and state government officials, and
politicians;
Indirectly (through health education publications and local activities of individual CMAI
members) CMAI reaches a population of about 5 million. CMAI knowledge and expertise
is spread and shared on the international level through networking and connections with
the World Council of Churches.
CMAI has a well-qualified board consisting mainly of leading persons in the field of
Indian curative and preventive health care. It has a competent, professionally skilled staff
of 86 persons (about one third of the members of board and staff are women). Largest
divisions of CMAI are: community health department, general administration, and
department for human resources. Before 1985, CMAI had twelve offices apart from its
head office. In 1985, the number of offices was reduced to four. It is the intention of
CMAI to further reduce this to two offices (Delhi and Bangalore).
CMAI maintains a good working relationship with other NGO's, especially with the
Catholic Health Association of India (CHAI) and the Voluntary Health Association of
India (VHAI). In cooperation with the first, CMAI organizes health ministry work in
Christian churches, carries out research and study programmes, and is engaged in
establishing a community health cell in Bangalore. CMAI advises VHAI members to
become members of the state-VHA in their state. Working relationships are good, and
CMAI avoids duplication of activities carried out by the state-VHA's (like, for instance,
the publication of health periodicals). The directors of CHAI, VHAI and CMAI have
regular (4 monthly) meetings.
113
6.6.
Rajasthan Voluntary Health Association, Jaipur, Rajasthan (RVHA): support
to RVHA programme 1993-1997
: Rajasthan Voluntary Health Association
(RVHA), Jaipur, Rajasthan
Proj ect/programme : Support to RVHA programme, 1993-1997
: state level
level
: urban and rural
urban/rural
Organization type : intermediairy (service and support)
: IN 145011 934061
File number
: four years (1993-1997)
Commitment
: total
: Dfl. 425.185,Financing
own contribution
contribution Icco : Dfl. 425.185,Organization
RVHA is a secular intermediary (support) organization with a large membership of NGO's
operative in Rajasthan. RVHA was established in 1991 as an independent organization, in
close cooperation with its national umbrella organization, VHAI. It has in the first place a
platform-, training-, motivational and lobbying function. RVHA originates from the
cooperation between NGO's in the wake of research done by VHAI during 1985-1987
drought period in Rajasthan. More than 100 NGO's were involved in the preparations for
the establishment of RVHA in 1991. In 1992, RVHA was formally recognized by the
government and has received a FCRA number.
The state of Rajasthan covers a total area of 342.239 km2. It is characterized by a
generally low level of socioeconomic development. Nearly eighty percent of the
population live in rural areas and depend on agriculture for their subsistence. In 1990,
almost half of the total land area was brought under cultivation. However, only one fifth
of the cultivated land is irrigated, the remainder is rainfed. The health situation of the
majority of the population (particularly of women and children) is bad. Mortality and
morbidity indicators for Rajasthan are higher than the Indian national averages of these
indicators. Another major problem is environmental degradation (a.o. desertization and
shrinking reserves of drinking water). Women find themselves in a socially inferior and
isolated position. The bad health position of women is clearly illustrated by a sex ratio of
912/1000 (for an extensive overview of the health situation, see: Status of Health in
Rajasthan, RVHA 1993). There is a great need of good NGO's to address these problems.
As RVHA has developed an adequate programme which is in keeping with Icco policy
priorities, Icco has decided to finance RVHA.
From 1983, Icco has supported VHAI, a secular organization with a platform function at
the national level. During the last few years, a gradual process of decentralization and
delegation of activities to the state-level (state VHA’s) has set in. In this process skills,
knowledge and experience of VHAI can be optimally used in establishing state VHAs.
VHAI consolidates its position as a national support and umbrella organization, continues
to function as a national forum and retains its lobbying function at this level. But for the
near future priority will be given to the establishment and growth of the state-level
organizations (state-VHA's), which are in a better position to concentrate their objectives
and activities on state-specific organizations, issues and health problems.
114
Icco has started financing state VHA’s in the eighties. It has sponsored the state VHA of
West Bengal until 1990. In 1991, funding of Rajasthan VHA and Assam VHA began.
Later, in 1994, Tripura VHA was added. In 1991, Icco supported the VHA’s of Rajasthan
and Assam with a onc-year starting subsidy (project 913059). In Rajasthan, during this
period the organization and its network was built-up, policy priorities were set, staff was
attracted and a number of specific activities started (eye diseases, medicine use, youths
and women). In 1992, a one-year continuation of Icco support was granted (project
923326; Dfl. 122.482,-). Next to ongoing activities, RVHA concentrated on campaigning,
training, lobbying and further strengthening of NGO networks. In 1993, RVHA had a total
membership of some 50 NGO's. The contribution of Icco to the current programme
(1994-1997) concerns a continuation of the main activities of RVHA during the preceding
period.
The general objective of RVHA is to develop a broad-based health movement which
strives for a better health care in Rajasthan, greater access to health facilities and a better
health status for the poor segments of Indian society. RVHA supports NGO's involved in
the implementation of health programmes. It provides training, information, education and
training of village health workers (VHW’s). Specific points of attention are: environmental
issues; strengthening of the position and improvement of the health situation of women;
information to the general public; training of VHW’s; information on over-use of
medicines; prevention of exploitation by quacks; quality and availability of drinking water;
and common occupational diseases (e.g. tuberculosis and silicosis).
The main short-term and mid-term objectives of RVHA are:
strengthening the common forum of voluntary organizations in Rajasthan, to focus
on shared concerns and undertake joint action programmes;
to improve the functioning of government state health services via liaison with
voluntary organizations and interaction with the state government, the medical and
health department, the IEC bureau and public health engineering department
(PHED);
to improve, via training, supply of information and interaction, the functioning of
medical professionals and traditional health practitioners;
to mobilize public opinion against irrational health care, unnecessary drugs,
unqualified sex determination tests, abortions and the malpractices of quacks;
to increase the level of knowledge among the public about health and healthrelated issues through campaigns, exhibitions and the distribution of documentation
materials;
to improve the status of women’s health through research, development of
information material, and activities in the field of advocacy;
to execute relevant studies and research in order to collect proper information and a
solid basis for the planning and action of RVHA activities and interventions.
Important points of attention are:
stimulating the further strengthening of primary health care activities of member
organizations;
the interaction between factors influencing health and the prevention of diseases;
115
stressing the importance of the role of other sectors;
paying attention to state-specific problems (main problems in Rajasthan are: child
mortality, nutrition, safe water supply and water-borne diseases, occupational dis
eases (TB, silicosis) women's diseases, diseases caused by ecological degradation,
and addictions (alcohol, opium).
The main activities of RVHA to reach the objectives described above are:
A.
B.
C.
D.
research activities on environmental problems, preventable communicable diseases,
occupational health hazards, women health workers, primary health centres, AIDS,
privatization, the voluntary sector in Rajasthan, and the evaluation of national
health programmes;
campaign and lobbying activities on the impact of pesticides on health, waterrelated health problems, occupational health hazards, rational drug use and other
issues;
training activities on various subjects for diverse target groups as, for instance,
TBA's, VHW's, school teachers, women's health and adolescent girls;
communication activities, through a communications team, exhibitions, and the
production of RVHA publications in local language;
Direct target groups of RVHA are:
1.
2.
3.
4.
the partner organizations which are involved in a variety of activities, including
health, education, research, environmental rehabilitation, water conservation,
income generation, safe water supply etc. RVHA plays a facilitating role through
the motivation, training and improvement of the total functioning and performance
of these organizations;
the general public;
the members of the State Legislative Assembly (for lobbying activities);
government health functionaries (for liaison work with NGO's);
Indirect target groups are the poor and neglected sections of the population of Rajasthan
(including tribals and dalits in the Aravalli hills and Thar desert).
Recently RVHA has internally evaluated its own performance, achievements and
constraints. It was concluded that results were satisfactory form the point of view of the
amount of response and activities of the member-NGO's. On the other hand, activities
were found to have too much an ad-hoc character, and not to be based on systematic
research and analysis of the health situation in Rajasthan. RVHA then decided to execute a
rapid health survey. The proposal for the current programme (1993-1997), supported by
Icco is based on the outcome of this study.
RVHA gives much attention to the quality of its relationship with the government and its
representatives. RVHA systematically tries to expand and improve these relations, in order
to be able to strengthen its intermediary role between NGO's and government agencies.
Increasing presence of government functionaries in training courses, meetings and
workshops forms a sound basis for the further expansion of future cooperation.
116
RVHA has a board consisting of competent and experienced members of NGO's with a
long working experience in Rajasthan. A minority of the board members are women.
RVHA staff comprises an executive secretary, an administrator, a researcher, a campaign
leader, a communications coordinator, a publicity coordinator, and a support/administrative
staff of five persons. The majority of personnel in all staff segments are women. A large
turnover of qualified staff has been a major constraint during the first years of RVHA's
existence.
117
6.7.
International Nursing Service Association (INSA), Bangalore, Karnataka:
Rural Health and Development Trainers Programme 1991-1994 (1995)
: International Nursing Service Association
(INSA), Bangalore, Karnataka
Project/programme: Rural Health and Development Trainers
Programme 1991-1994 (---> March 1995)
national
level
predominantly rural
urban/rural
Organization type intermediate (service and support)
IN 15991 (913043)
File number
three years (1991-1994)
Commitment
: Dfl. 193.175,total
Financing
5.217,: Dfl.
own contribution
77.901,: Dfl.
private contrib.
contribution Icco : Dfl. 110.057,Organization
INSA is a secular organization, based in Bangalore, Karnataka. In 1982 INSA was
established as an independent organization, but with affiliations to the USA-based
International Service Association for Health. Since 1972 INSA-USA organizes health
education programmes for health workers and community leaders from Third World
countries. The INSA network comprises 42 countries (of which INSA-India is the only
independent division). INSA is formally recognized by the government, and has a FCRA
number.
The objective of INSA-India is to train staff involved in carrying out health care activities
to improve their activities so that they can play a more effective role in the promotion of
community-based health care programmes related to community development initiatives.
Special attention will be paid to train the staff to become good trainers of local VHW's
Main activity of INSA is organizing training in the fields of basic health care and
development for nurses and other health personnel from various NGO's in India. These (10
weeks') courses are held twice a year. Much attention is paid to the follow-up of these
courses, trainees are at least once visited in the field, and special workshops are organized
for former trainees. Next to that, INSA organizes small workshops in which certain
aspects of health care are dealt with. More specific:
to conduct every year at least two rural health and development training courses of
ten weeks' duration, with a minimum of 15 participants;
to conduct follow-up visits by INSA staff to assess the effectiveness of the training
and to offer further help to the participants, if required. Contact with all graduates
will be maintained through a newsletter and an update;
participants from each course, on completing one year of work in the field, will be
invited by INSA for a two or three days' regional workshop to share and evaluate
their performance in the field;
to build up the core group members to at least 85 persons, and to conduct one
workshop with the core group every year;
to conduct AIDS education in high schools/junior colleges in Bangalore;
118
specialized training programmes for various organizations on request, and
consultancy work.
The first target group are participants (nurses, paramedical workers etc.) of the courses
from institutions or organizations all over India involved in rural community health care,
especially from the southern states. Some eighty percent of the trainees are women. The
second target group are the organizations to which to trainees are affiliated. The third
(indirect) target group are the (rural) communities in which trainees will apply their skills
and knowledge.
Icco has supported INSA since 1983. Between 1983 and 1987 Insa was supported on a
yearly basis. As experiences in these years were very positive, in 1988 the first three
years' agreement was concluded (1988-1991). The programme currently funded by Icco
is a continuation of the activities carried out in the period 1988-1991. The decision by
Icco to continue financial support to INSA is based on the consideration that, in view of
the general shortage of qualified and motivated health care staff, there is a great need for
programmes like the one implemented by INSA.
Apart from the activities mentioned above, INSA carries out no other programmes or
activities. It is financially supported by Icco and INSA-USA. For a new (3 years)
programme on AIDS education, INSA receives Rs. 7,5 lakh from Ford Foundation. INSA
raises its own funds on a small scale, through consultancies and the organization of
workshops.
INSA has a board consisting of six members (four of which are women), all of which
have extensive working experience with all kinds of social work (law, management, health
care). INSA staff consists of six qualified people, who are all women.
In 1989, INSA has been evaluated (on its own initiative). Special attention was paid to the
following items: organization and management; quality and methodology of the training;
impact of the training on other programmes and ’community change and awareness’. The
outcome of this evaluation was very positive for the training programme of INSA and its
impact on other organizations and communities.
Some recent (1993) critical remarks made about the organization:
in 1993 there was a stagnation in the number of registrations for the training, while
among health personnel there is a continuing demand for the kind of training
offered by INSA. What about INSA's networking and P.R. activities?
it is not clear whether INSA is successful in its objective of stimulating other
NGO’s to give the kind of training provided by INSA;
all training courses are in English. Are there any possibilities to organize them in
other languages like Hindi or Tamil in the near future?
119
During a recent visit it became clear that the low number of registrations is partly caused
by the fact that the number of trainees is restricted as a matter of policy (to maintain the
high quality of the courses). However, another reason is that for many women it is still
difficult (regarded as socially unacceptable) to follow a training course. As to the problem
of language: the issues of regionalization and the organization of training courses in local
languages are main points of attention in future INSA policy.
120
6.8.
ACHAN (Asian Community Health Action Network), Madras, Tamil Nadu:
Community-Based Action for Transformation in Asia
: ACHAN (Asian Community Health Action
Network), Madras, Tamil Nadu
Project/programme : Community-Based Action for Transformation
in Asia (proposed)
level
: Asia/India
urban/rural
: urban and rural
Organization type: intermediary/umbrella organization
: AZ 893228
File number
: three years (1994-1997) (proposal currently
Commitment
under consideration)
: Dfl. 2.100.000,: total
Financing
: 60% (EZE)
other donors
850.000,contribution Icco : Dfl.
(under consideration)
Organization
ACHAN is an international, secular non-governmental umbrella organization active in the
health sector. ACHAN was established in 1980 by a group of health activists with
extensive experience in basic health care in Asia. Since its establishment ACHAN
functions as the meeting point of a large number of organizations active in the field of
primary health care in various countries in Asia. Within Asia, priority is given to Nepal,
Bhutan, Kampuchea, Burma, Bangladesh and Indonesia. ACHAN is registered in Hong
Kong, with offices in Madras and Bangkok.
A focal point in ACHAN's analysis of the health situation in Asia is, that the main causes
of the bad health situation in Asia can be found in the sociopolitical and economic
spheres. Nutritional deficiencies (nutritional blindness, retarded growth), water-borne
diseases (infective hepatitis, cholera, typhoid, amoebiasis etc.), and many other povertyrelated diseases continue to make many victims among the Asian poor.
At the same time, access to education is primarily restricted to the ruling classes. Growthoriented development has become a major threat to the environment, and further added to
the plight of the poorest groups in society. Under the existing national and international
sociopolitical and economic structures, the majority of poor people are denied basic human
needs and basic human rights.
According to the analysis made by ACHAN, the voluntary sector (NGO's) has, generally
speaking, not been able to change this situation. Usually NGO’s have become part of
mainstream development practices and helped to increase the existing social disparities.
ACHAN tries to be an alternative network which aims at bringing about a fundamental
change in the thinking and practice of NGO’s, enabling them to see the vision of an
alternative society, and capacitating them in achieving it. In the field of health care,
ACHAN promotes an integrated approach with a high local level of participation by the
target group in planning, implementation, monitoring and evaluation.
121
The general objectives of ACHAN arc to promote and improve community-based health
care programmes and rational drugs policies in Asian countries to bring people's health in
people's hands. More specifically:
to facilitate the formation of national grass-roots networks and task forces on
community-based health care;
to strengthen programmes aimed at training, motivation and orientation of mid
level health workers;
to influence policy makers in favour of community-based health care;
to improve the effectiveness of health care programmes from the point of view of
women;
to make educational institutes like universities more supportive to community
based health care;
to increase the use of community resources like indigenous drugs and practices;
Main activities carried out by ACHAN to achieve these objectives are:
organizing exchange and training programmes for management and staff of
organizations active in primary health care through participatory training
methodologies (PTM). Special attention is given to the role of women in health
care, and to the strengthening of this role;
research on the effects of the much criticized large-scale programmes of
international (multilateral) organizations;
the improvement of government programmes through lobbying activities, training
for government personnel, and direct cooperation with the Ministries of Health;
involvement in the establishment of a health care programme in Kampuchea, in
collaboration with the World Council of Churches.
In the project description for the ACHAN programme 1990-1992 the following specific
activities are mentioned: training for mid-level workers; promotion of community-based
health care programmes; mid-level curriculum formation; herbal medicines; women in
health; alternative medical education; Asian apex bodies; follow-up; participatory action
research; special initiatives (Kampuchea); publication (the quarterly magazine LINK, and
handbooks on various topics).
The main target group are mid-level health workers and health trainers of organizations
involved in promoting and implementing community-based health care programmes.
Another target group are the coordinators and managers of community-based health care
programmes and government officials responsible for the preparation of decision-making
on health care and for the implementation of health care policies. Special attention is paid
to the involvement of women in all programmes.
Icco supports ACHAN since 1983. All foregoing Icco commitments comprised a limited
number of activities out of the total ACHAN-programme. Other donors of ACHAN are
EZE, Misereor, Brot fur die Welt, CIDA and UCC-USA. In the last few years, EZE has
been the major donor of ACHAN.
122
ACHAN differs from most organizations active in the field of health care supported by
Icco. First, it is an international organization with Asia as its area of operation rather than
India, as its area of operation. Second, the ACHAN approach and organization differ
somewhat from the pattern generally found, in that its networking and training activities
and seminars seem to be rather loosely structured and to lack any follow-up.
Therefore, there are doubts about the precise significance of ACHAN for the health sector
in India. It is not very clear whether ACHAN has a great impact as an innovating and
alternative network in the Indian health sector.However, in the (international) Asian
context of health NGO's ACHAN seems to play an important role as a promotor of equity
in health, community-based health care, rational drug use, and radical reorientation of
curricula.
Recently, ACHAN has developed plans for decentralization of activities through 'core
groups', 'country coordinators' and country profiles. Thus, the strategy of ACHAN can be
more intensively and effectively oriented towards specific countries. At the same time, the
regional office will be able to concentrate on coordinating regional (Asian) activities
(workshops, training, exchange programmes etc.), facilitation, stimulation and support.
Neither progress reports nor the external evaluation (1992-1993) recently carried out
throw more light on the scope and impact of the ACHAN programme in India. Moreover,
in the wake of the evaluation, new questions were asked and even doubts were raised
about the importance of ACHAN as a network organization, both in India and in the
international context.
123
7.
RECOMMENDATIONS FOR SELECTION OF THE EVALUANDUM
7.1.
Introduction
As has been shown in the above chapters on the projects and programmes of Cebemo and
Icco, a preselection has been carried out by these organizations in preparation of the
choice of the evaluandum.
In this final chapter the recommendations for choice of the evaluandum as have been
presented to the team, as well as the definitive choice agreed upon by the team are
rendered. While choice was limited due to the fact that a preselection had already been
made out of a total of more than 109 projects and programmes, it has been tried to base
this further choice as much as possible on the following elements:
1.
2.
3.
7.2.
relevance in the light of the research questions in the preliminary terms of
reference (TOR);
relevance in the light of a number of thematic points of attention and further
operationalizations as presented in the preliminary terms of reference.
relevance against the background of societal developments in India and, more
specifically, of important developments in the NGO-world and the position of
NGO-actors in society.
Recommendations: Cebemo
With respect to the preselection of programmes eligible for evaluation, some remarks seem
appropriate. We feel that the element of choice in determining the evaluandum was in
practice very limited. Of the seven programmes that were preselected, two (KSSS and
TRU) fell off for logistical reasons (accessibility and location in relation to the main
clusters of preselected programmes). Thus, in practice, four programmes had to be chosen
out of five.
The first criterium used for preselection (larger projects or programmes) may be
understandable from the point of view of efficiency of an evaluation mission that has to be
carried out within severe time constraints, but there remain some questions when
considered from the point of view of the composition of the total package of healthrelated activities of Cebemo.
From the data given below it can be seen that 66% of the total number of health-related
projects and programmes belong to the two lowest categories (cat. A and B), with the
great majority in category A. Moreover, total amounts of funding per category do not
significantly differ. However, none of the preselected programmes belong to one of the
’small’ categories (A or B).
124
A
B
C
D
E
F
G
Total
0- 50
> 50-100
>100-150
>150-200
>200-250
>250-300
>300
Ill
II
I
53
19
14
7
7
4
5
1.127.308
1.467.718
1.682.059
1.261.341
1.570.438
1.119.667
2.100.534
(48,6%)
(17,5%)
(12,8%)
( 6,5%)
( 6,5%)
( 3,6%)
( 4,5%)
(10,9%)
(14,2%)
(16,2%)
(12,2%)
(15,2%)
(10,8%)
(20,3%)
10.329.065 (99,8%)
109 (100 %)
Source: Cebemo; list of projects with health component
currently in implementation (5-9-1994)
I
: commitment by Cebemo (x Dfl. 1.000)
II : number of projects (and percentage of total number)
III: total amount per category (and percentage of total)
Apart from the fact that the criteria for distinguishing 'larger' projects are rather vague,
some other observations can be made. First, while small 'grassroots' and directly targetgroup oriented activities are part of the 'trade mark' of Cebemo, the numerically important
category of smaller projects (A/B) is not represented in the evaluandum. Unless the
ultimate criterium for selection is 'money moved per project', their exclusion is
questionable.
Second, and related to the first remark, in the light of the TOR and (key) research
questions of the mission the position of small projects might even be very important
indeed. How do such small interventions relate to their institutional environment? Are they
isolated 'islands' or are there forms of cooperation with government agencies and NGO's?
Particularly, how do they relate to health services and infrastructure at the local level (e.g.
district) These and other questions have a direct bearing on the TOR questions.
Further, and important against the background of the TOR, could it not be the case that
the smallest interventions are institutionally the most isolated ones, and the ones most in
need of support? In that case their inclusion would seem essential. The more so, if it is
realized that most of the projects that have been (pre)selected have not a purely
implementing, but also an (in some cases rapidly developing) intermediary/supportive
function.
Finally, it should be stressed here that future policy decisions by the CFA's on the kind of
implementing organizations to be funded or on the 'level' to concentrate support on may
well be based on considerations of the limited CFA-capacity to 'manage' a large number
of small projects and on the need for more local partners at a higher institutional level
(concentrating on intermediary, support, lobbying and networking functions) that can take
over 'decentralized' CFA-functions and responsibilities, rather than on answers to the key
questions of the TOR.
125
From the programmes preselected by Cebcmo, we propose to select the following
evaluandum (note that many points of attention mentioned for each programme are
important issues in other programmes as well):
1.
Bengal Rural Welfare Service (BRWS), Calcutta, West Bengal: Programme for
Rural Basic Health Care.
Important points of attention which may throw light on the long-term effectiveness and
sustainability of BRWS, and on the question of its possible needs for support are:
aspects of cost recovery (payment for sevices by the target group);
(related to the above point) the precise function and target group of the (urban)
Garia health center; is it a ’cash cow' among the urban middle class population for
financing other (rural) activities? Does it complement or replace government
services?
BRWS shows some characteristics relevant to the discussion about selective and
comprehensive PHC (family planning, growth monitoring);
in programmes in which BRWS cooperates with government services/programmes
like family planning: is BRWS an independent, innovative organization operating
complementary to, or an instrument of target-oriented government programmes?
What about other important BRWS-govemment relations (health services,
referral)?
what is the size of direct/indirect target groups? How do health service targets (e.g.
vaccination) relate to the size of the direct target group?
2.
Village Health Workers Scheme, Diocese of Berhampur, Orissa: Diocesan Training
Center and Programme of Rural Health Workers, Jaganathpur village
In this project, the following points of attention might contribute to a further
operationalization of the TOR into research questions:
what are, in this particular case, the main causes of the high drop out rate of
VHW’s? Is there any direct relation with the issue of payment of VHW’s?
to what extent has the programme in fact taken over health care responsibilities of
government agencies rather than complementing them?
(relating to the discussion about comprehensive/selective PHC and the long-term
effectiveness of intervention): do the training course and the programme surpass
curative approaches to health care? Is the programme responsive to recent
developments in the field of health (AIDS; STD’s in general), and are such issues
reflected in the curriculum for VHW’s?
are there signs that the programme is biased towards Christian segments of the
target group? At the institutional level, how does a programme within a diocesan
administrativer like Berhampur
126
3.
St. Thomas Mission Society, Mandya, Karnataka:
Community-Based Health and Development Programme
With reference to this programme, the following points of attention might be relevant to
the mission:
the urban component of the programme. Though Mandya is a small town, it might
be useful to pay attention to a directly target-group oriented programme like the
slum development programme, especially in view of the weak representation of
urban activities in the preselected programmes.
to what extent have group formation and education among the target group become
an end in themselves? Especially in the field of education there seems to be a gap
between felt priorities and needs of the target group and the ideological
preoccupations of the programme.
to what extent has the programme succeeded in maintaining and strengthening its
comprehensive orientation? Are the various activities well-integrated, or segmented
and unconnected, each with its own targets?
4.
Christian Council for Rural Development and Research (CCOORR), MAGR
District (Vengal), Tamil Nadu: Rural Health Training Center and Extension of
Field Activities
Some possible points of attention are:
innovative approaches visible in the training programme;
aspects of 'self-reliance'; under what conditions are (parts of) the target groups
supposed to have become self-reliant? Are there any criteria for cost-recovery, the
position of VHW's etc.?
how does the two tier-system of micro and macro centers relate to government
health institutions at the local and district levels? The proximity of local town
centers seems to create a favourable condition for cooperation in health care
programmes. How do representatives of the traditional local system, like TBA's,
relate to the government structure of health care, if present?
Karuna Social Service Society (KSSS), Diocese of Bijnor: Community Health
Programme: not selected for logistical reasons.
Trust for Reaching the Unreached (TRU), diocese of Ahmedabad, Gujarat:
Comprehensive Primary Health Care, Panch Mahals, Gujarat. Diocese of
Ahmedabad: not selected for logistical reasons.
Peermade Development Society (PDS), Kerala, India: Integrated Health and
Development Programme: this programme shows many of the characteristics that
are also found in Mandya. In view of the fact that Mandya contains an urban (slum
development) component, this programme has been chosen instead of PDS.
127
7.3.
Recommendations: Icco
With respect to the preselection of programmes, the same remarks can be made as for
Cebemo. In particular, the criteria used for preselecting the programmes/organizations
mentioned in chapter 6 have not been made explicit.
Further, the remarks made above (chapter 6) on part of the preselected organizations
(INSA, ACHAN and ASSEFA) make clear that the choice of the evaluandum was in fact
more restricted than suggested by the number of preselected organizations. Further, at the
request of ICCO, CMAI was also excluded from the proposed evaluandum, and will be
visited as a 'resource organization'.
Considering the above, from the programmes preselected by Icco we propose to select the
following evaluandum:
1.
Child In Need Institute (CINI) (IN 019021)
Points of special interest are:
experiments with a new strategy for decentralizing health care through the Village
Development Forum (instead of exclusively through women’s organizations);
attention to the gradual phasing-out of activities, through a distinction between the
A, B and C villages;
cooperation with the government programme for Development of Women and
Children (DWCRA);
2.
Ashish Gram Rachna Trust/Institute of Health Management Pachod (AGRT/IHMP)
(IN 074051).
The following points might be of special interests for the mission:
the combination of fieldwork, research, training and the running of a hospital;
cooperation with government programmes and agencies at the taluk level;
systematic attempts at application of new approaches on a larger scale;
Alternative approaches to the governmental Integrated Child Development Scheme;
extension of activities and processes of 'scaling up'; what are the consequences for
the quality of AGRT programmes?
3.
Voluntary Health Association of India (VHAI) (IN 123041)
Being one of the most important health-NGO’s in India and, moreover, the
umbrella organization of state-level organizations like RVHA, VHAI has been
included in the evaluandum (to replace CMAI; see above).
128
4.
Rajasthan Voluntary Health Association (RVHA) (IN 145011)
In our opinion RVHA should be included in the evaluandum because this state
level organization is the exponent of an important process of decentralization
started by the national organization VHAI, and now covering most states.
Not selected as part of the evaluandum for reasons mentioned above:
Christian Medical Association of India (CMAI) (IN 142021)
International Nursing Service Association (INSA)
(IN 073011)
Asian Community Health Action Network (ACHAN) (AZ 893228)
Association of Sarva Seva Farms (ASSEFA) (IN 057041)
129
1). The WHO defines health as '..a state of complete physical,
mental and social wellbeing, and not merely the absence of
disease or infirmity'; a state unknown to ordinary mortals.
The main social target of 'health for all' was the attainment
by all citizens of the world of a level of health permitting
them to lead a socially and economically productive life
(WHO/UNICEF, 1978) .
2). A major obstacle is the artificiality of 'sector thinking'
through which interrelated problems like health and nutrition
are separated. There is still a tendency both among donors and
receiving governments and organizations to call any activity
carried out a 'sector' and fund them accordingly.
3). However, on a per capita basis, central government
expenditure in many developing countries shows a decrease in
real spending. Moreover, data on the percentage of national
expenditure allocated to local health services are scarce. If
available, these data show stagnation in developing countries
and a decrease in the least developed countries (WHO, 1993;
139-140) .
4). According to WHO (1993a) one of the major constraints in
the second evaluation of the 'health for all’ strategy, is the
lack of information about the achievements of member states in
implementing their national strategies (WHO, 1993a; 138).
5). Rohde et al. (1993; 507-509) relativate the dichotomy
between 'selective' and 'comprehensive', 'vertical' and
'horizontal' approaches. At the level of implementation, they
argue, such a polarization has never existed. All programmes
are the product of choices and compromises, and the outcome is
never exclusively 'selective' or 'comprehensive'. 'Selective'
programmes even tend to produce more 'horizontal' results than
'comprehensive' programmes.
6). While such decentralized health systems are generally
called ’district health care’, the optimal level of decentra
lization will of course depend upon specific circumstances in
the country concerned (WHO, 1988a; 9).
7). The 'Operation Research Group' (ORG) of Baroda University
gives higher population estimates, amounting to 908 million in
1991, and an estimate for 2021 of 1,4 billion. Only by the
year 2025 will population growth have decreased to a level
below 1% per year, according to ORG (DGIS, 1992).
8). Linguistic differences are the foundation of many of the
present states.
9). For the state of Bihar, see Das, 1992.
10). Currently, India is implementing its eighth Five-Year
Plan (1992-1997).
130
11). For further remarks on the determination of the poverty
line, see Shah, 1991 (footnote 36).
12). see, a.o. VHAI, 1991, and a recent article in NRC
Handelsblad (van Straaten, 1994).
13). Such autonomy and room for manoeuvre for NGO’s may even
increase in situations of decreasing state capabilities and
responsibilities associated with structural adjustment pro
grammes and the consequent drawing back of national states.
14). These same factors account for the large degree of
concentration of Cebemo's NGO-partners (’preferential
partners’) in South India (Tamil Nadu, Karnataka, Andhra
Pradesh, and Kerala) (Cebemo, 1989).
15). Shah estimates that only about five percent of the Indian
NGO’s (the ’social action groups’, often with a Marxist back
ground) do not wholly subscribe to the government’s develop
ment perspective (1991; 16).
16). This section is mainly based on two recents publications
on Dutch development assistance to India (DGIS, 1992 and DGIS,
1994). For an extensive account of the history of Dutch
development assistance to India, and especially the role of
Dutch commercial interests in determining the composition of
the aid package, see DGIS, 1994.
17). Dutch development assistance consists of a regular
programme (annual allocations to the priority countries
involved), and a non-regular programme (involving other
programmes, like the sector programmes and the allocations to
the four co-financing agencies).
18). See DGIS, 1994. According to DGIS, 1992 this ’streamli
ning’ of development assistance was introduced in the 19881992 policy plan.
131
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134
Datum: 05/09/94
Overzicht Gezondheidsprojecten Indi^ in uitvoering
Projektnummer
Nederlandse titel
Plaats van Uitvoering
M 317 00149 B
C 317 01033 C
C 317 01130 A
C 317 01148 A
C 317 01157 C C
C 317 01182 C
C 317 01185 A
C 317 01216 A CE
E 317 01216 A EC
C 317 01227 A
C 317 01239 E
C 317 01260 A
C 317 01271 B
C 317 01280 D
C 317 01292 A
C 317 01293 A
C 317 01294
C 317 01430 A
C 317 01498 A
C 317 01505 D
C 317 01575
M 317 01610 A
M 317 01632 A
C 317 01673 D
C 317 01776
C 317 01786
C 317 01893 R
C 317 01918
C 317 01954
CT
C 317 02027 B
C 317 02047 A
M 317 02047 B
C 317 02060
C
M 317 02183
C 317 02195 A
C 317 02195 R
C 317 02209
C 317 02283 R
Gezondheidszorgprogramma
Devi kapuram
Basisgezondheidszorg en ontwikkelingsprogramma
Gezondhei dszorgprogramma
Basi sgezondheidszorgprogramma
Basi sgezondheidsprogramma
Gemeenschapsontwi kkel ingsprogramma
Consolidatieprogr. groepsgewijs ondernemersschap
Opleiding gezondheidswerkers
Opleiding gezondheidswerkers
Ontwikkelingsprogr.t.b.v. krottenwijkbewoners
Vernieuwing van informeel onderwijs
Programma voor geestelijke gezondheidszorg
Vrouwen-ontwikkel ingsprogramma in slums
GeTntegreerde plattelandsontwikkeling
Kodai kanal streekontwi kkeli ngsprogramma
School gezondheidsprogramma
Gemeenschaps-gezondhei dszorg
Gemeenschapsontwi kkel i ngsprogramma
Gezondhei dszorgprogramma
Hyderabad
Berhampur
Si ripuram
Biz: 001
Bi Aanvraqer
92
93
90
87
Raisen District
90
Gudipalli, Gollahalli
92
Lapung Block
93
Vejendla
88
Vejendla
89
Poona
90
Manvi
93
Delhi
90
Ghazi abad
90
Tumkur
94
Kodai kanal
90
Mananthavady
90
Dhamola
87
Rajkot
90
Narth-East India
91
Gemeenschapsontwikkelings- en gezondheidsprogramma Mandya
92
Gezondhei dszorgprogramma
Mokama/Patna
87
Gezondhei dsvoorli chti ng
Khedbrahtna
92
Vervoermiddel voor ruraal gezondheidszorgprogramma Bamhori
94
Programma voor gezondheidsz. en gemeenschapsontw.
Udumalpet Block
94
Gezondhei dsprogramma
Chi 1akaluri pet
88
Ontwi kkelingsprogramma voor slumbewoners
Ramarajvanagar
89
Gemeensch. ontwik. & niet-formeel onderwijsprogr.
Balasore diocese
89
Gezondheidsprogramma Bijnor Diocees
Bijgnor Diocees
89
Opleiding voor gezondheidswerkers
Narasaraopet
89
Geintegreerd ontwi kkel ingsprogramma
Peermade
93
Gezondheids- en educatieprogramma
Varusanadu
92
Programma voor gezondheidszorg en educatie
Varusanadu
94
Basi sgezondheidsprogramma
Ganjam
90
Gezondhei dszorgprogramma
Idappadi
91
Basisgezondheidsprogramma voor tribalen
Panchmahals
93
Basisgezondheidsprogramma voor tribalen
Panchmahals district
90
Jakkalli streekontwi kkeli ngspreject
Jakkalli
90
Vrouwenontwi kkel ingsprogramma
5 distrikten in Andhra Pradesh 90
ST.J.D.
CHAI
DIOC.BERHA
SOC.ST.ANN
A.B.H.C.
SUNANDA
X.I.S.S.
J.M.J.PROV
J.M.J.PROV
C. D.S.A.
GOOD.SH.S.
SANJIVINI
G.N.K.
R. E.D.S.
M.M.S.S.S.
JANA SAUKH
D. C.D.P.
DIOCESE RAJKOT
NECHA
S. TH.M.S.
M. N.H.S.
N. L.R.D.F.
R. D.S.S.
C.H.D.P.
ST.CH.CON.
VIJ.S.S.C.
MARSHAL D.
KSSS
SASSS
P.D.S.
S. A.M.
VSSS
U.A.A.
ARAISE
T. R.U.
T.R.U.
O. D.P.
SASSS
Bi jdraqe Cebemo
5.000,00
275.379,00
110.008,00
25.234,00
26.593,00
211.236,00
140.847,00
290.333,00
104.220,00
190.578,00
90.368,00
100.000,00
88.270,00
364.404,00
170.717,00
106.898,00
19.057,00
233.461,00
74.768,00
414.189,00
90.368,00
6.975,00
15.000,00
21.865,00
33.300,00
21.007,00
139.877,00
114.153,00
68.250,00
217.652,00
30.514,00
8.877,00
205.003,00
11.302,00
292.361,00
104.958,00
565.219,00
192.764,00
n)
Datum: 05/09/94
Overzicht Gezondheidsprojecten India in uitvoering
Biz: 002
Proiektnummer
Nederlandse titel
Plaats van Uitvoering
Bi Aanvraqer
C 317 02317 A
C 317 02407
C 317 02525
C 317 02580
M 317 02612 R
C 317 02613
C 317 02636
M 317 02644
M 317 02646
C 317 02683 A
C 317 02727 R
C 317 02737 A
C 317 02776
C 317 02822
C 317 02839 R
M 317 02851
C 317 02880
C 317 02940 R
C 317 02941 A
C 317 02967 R
C 317 02982 R
C 317 02983
M 317 03004 R
C 317 03006 R
C 317 03023 A
C 317 03024 R
C 317 03061
M 317 03065
M 317 03084
C 317 03120 R
C 317 03146
M 317 03197
M 317 03198
C 317 03208
C 317 03255
C 317 03268 R
C 317 03276
M 317 03366 A
Geintegr. ontwikkeling voor vrouwen en kinderen
Geintegreerd gezondheidsprogramma
Ruraal trainingscentrum voor gezondheidszorg
Gezondhei dszorgprogramma
Haalbaarheidsstudie medisch test-1aboratoriurn
Ruraal gezondheidszorgprogramma
Educatief ontwikkel ingsprogramma
Bewustwordingsprogramma voor tribalen
Bagalkot
Faizabad district
Bangalore
Samastipur district
Secundarabad
Chamba district
Chi ntamani
Garla Mandal
Warangal district
Kankadahad Block
Gudalur
Hyderabad
Gangaloor
Vi rar
Saran district
Kuli thalai
Bangalore
Guntur
Yepaganahal1y
Mayurbhanj district
Mangalore
Moodbidri
Changanacherry
Manapparai Taluk en Pudukottai
Anandapuram & Yedehalli
Honavar
Manipur
Dhenkanal
Jai si nagar
Secunderabad
Dakshina Kannada Dt.
Andhra Pradesh
Koraput Dt.
Singrauli region
Bangalore
Nationaal
Uchkagaon Block
Bi 1ki sganj
93
91
93
91
91
91
91
92
93
94
92
93
92
91
92
92
92
92
93
92
92
92
92
93
93
92
92
92
92
92
92
92
93
93
92
93
93
94
Verbetering onderwijs/gezondheidssituatie tribalen
Gemeenschapsopbouwprogramma
Tribaal gezondheidscentrum
CHAI Evaluatie
Basi sgezondheidszorgprogramma
Vrouwen- en jeugdontwikkeling
Trainingsprogramma in gezondheidszorg
Geintegr. ontwikkelingsprogramma
Bewustwordingsprogramma voor sloppenwijkbewoners
Woni ngherstelprogramma
Plattelands-ontwikkel ingsprogramma
Basi sgezondheidszorgprogramma
Gemeenschapsontwikkel ing in Jyothinagar
Gezondheidsprogramma op het platteland
T.B. controleprogramma
Gezondheidszorgprogramma
Alfabetisering en gemeenschapsopbouw progr.
Geintegr. gezondheidszorgprogramma voor platteland
AIDS-preventi e
Programma voor rurale gezondheidszorg
Gezondheidszorg- en bewustmakingsprogramma
Beurs voor coordinator gezondheidsprogramma1s
Trainingsprogramma voor sociale workers
Heruitgave van gezondheidsposters
Volwassenenonderwijs t.b.v. Savara Tribalen
Ontwikkelingsprogramma voor tribalen
Documentatiecentrum basisgezondheidszorg
Basi sgezondhei dszorgprogramma
Gezondhei dszorgprogramma
Geintegr. plattelandsontw. programma
SEEDA
PAN I
S.J.M.C.
JPSSA
CHAI
ARPANA
MANUSH
C.M. GARLA
CAFP
ASHA
ASHWINI
CHAI
TERA PREM
VHDS
SZSVSS
SEVAI
JANODAYA B
DIOC. GUNT
SUMANA
DULAL
A. C.E.S.
MRCI
CH.S.S.S.
TMSSS
S.N.S.
B. P.K.
RDO
MLM
MVSS
CHAI
PRAJNA CC
APVHA
VINCENT'S
SLS
COM HEALTH CELL
CHAI
KARUNALAYA
SHANTI BH.
Bijdraqe Cebemo
127.935,00
66.028,00
52.640,00
16.870,00
9.867,00
120.004,00
129.990,00
13.400,00
13.568,00
41.830,00
241.152,00
108.571,00
27.834,00
82.052,00
26.270,00
9.912,00
79.583,00
191.609,00
72.994,00
33.501,00
74.900,00
31.330,00
15.000,00
80.505,00
138.422,00
171.635,00
334.217,00
5.965,0(1
6.965,00
36.245,00
79.138,00
6.600,00
6.531,00
117.472,00
75.855,00
39.522,00
22.156,00
15.000,00
Datum: 05/09/94
Overzicht Gezondheidsprojecten India in uitvoering
ProjeRtnummer
Nederlandse ti tel
Plaats van Uitvoering
C 317 03401
C 317 03411
C 317 03412
H 317 03413
M 317 03433
C 317 03458
C 317 03470
C 317 03590
C 317 03591
M 317 03613
C 317 03648
C 317 03661
C 317 03677
C 317 03701
M 317 03710
M 317 03726
C 317 03734
C 317 03741
M 317 03754
C 317 03778
C 317 03799
C 317 03802
C 317 03805
C 317 03840
C 317 03875
H 317 03885
H 317 03889
H 317 03892
M 317 03893
H 317 03909
H 317 03912
C 317 03913
C 317 03962
GeTntegreerde stedelijke ontwikkeling
Ahmedabad
Madras
Urutur
Singhbhum dist.
Dhenkanal dist.
Nilgiri, Wayanad, Calicut
Gujarat
Bombay
Bombay
Aids bewustwordingsprogramma
Gemeenschapsopbouw
Gemeenschapsontwi kkel i ngsprogramma
Gezondheidszorg en educatie programma
Preventieve en curatieve gezondheidszorgprogramma
Aids preventie
Volksgezondheidsprogr. voor sloppenwijkbewoners
Onderzoeksprogr. gemeentegezondheidszorg
Gezondhei dsprogramma
Aids preventie via bewustwordingsprogramma
GeTntegreerd gezondheidszorgprogramma
School gezondheidsprogramma
Gemeenschapsopbouw via juridische assistentie
Moeder en Kindzorg programma
Gezondhei dsprogramma
Gemeenschapsgezondhei dszorg
GeTntegreerd ontwikkel ingsprogr. voor slumbewoners
Gezondhei dsprogramma
Gemeensch. ontw. via sociale woningbouw
Gezondheidsprogrammaambalpur Action Group
Vrouwenprogramma
GeTnt. gemeenschapsontwikkeling t.b.v. tribalen
Trainingscentrum voor rurale gezondheidszorg
Ontwikkelingsprogramma t.b.v. vrouwen
Programma voor vrouwen en kinderen
Verbetering v.d. positie van tribale vrouwen
GeTntegreerde plattelandsontwikkeling
Gemeenschapsontwi kkel i ng
Wederopbouw rampgebied via gemeenschapsontwik.
Sociaal opbouwwerk door org. onderwijs en voorl.
Gezondheids-en onderwijsprogramma t.b.v. slumbew.
Mobiele gezondheidszorg centrum
Biz: 003
Bl Aanvrager
93
93
93
94
93
93
93
93
93
Patia/Bandhamunda Gramapanchy. 94
Dindigul-Anna District
93
Faizabad Dt.
94
Mananthavady
93
Nagpur
93
Pratapgarh
93
Pattamundai Block
94
Bombay
93
Bangalore
94
Derabish block
94
Peddavadlapudi
94
Rengali Block
94
Baliapal & Jaleswar Blocks
94
Barrack Valley
94
Vengal, M.G.R. District
94
Chotanagpur
94
Gajwel Taluk
94
Bi har/Madhupur
94
Sunghbum
94
Awandapur Block
94
Latur
94
Medak District, Andhra Pradesh 94
Bhubaneswar
94
Gania Block
94
Bijdrape Cebemo
SAATH
DESK
ST.J.CH.
S.L.A.D.S.
ABAJ
MSMI
GAP
FRCH
FRCH
PYS
SARADADEVI
ISWRDES
MANANTHAVADY
L.A.C.
MVSS
GARRVO
ALERT INDIA
ST. MICHAEL'S
CCD.
GDSS&WS
MASS
SBP
SKS
CCOORR
HCSSC
SAID
V.A.K.S.
SLAC
SAWP
S.A.K.
PRAGATHI
SJA
GUC
( 109)
118.704,00
90.146,00
31.257,00
5.253,00
6.903,00
41.738,00
241.542,00
48.544,00
42.323,00
6.680,00
34.882,00
21.425,00
48.764,00
28.238,00
13.591,00
7.225,00
261.594,00
422.505,00
5.676,00
187.399,00
17.899,00
19.477,00
63.993,00
156.639,00
220.392,00
57.832.00
17.344,00
14.496,00
5.963,00
80.028,00
29.736,00
49.996,00
26.808,00
10.329.065,00
I C C O
Z E I S T
27-09-1994 13:17
Pagina 1
Gebruiker MV
Bedrijf 001 Officiele administratie ICCO
6.1
Gezondheidszorg [ESPVS]
Clustercode: alle; Land van uitvoering: IN; Behandelaar: alle; Naam aanvraag: alle.
Cluster
Proj ectnr.
Prj r
LvU
INDIA
IN142021
IN095041
IN106031
IN123031
IN122O21
IN145011
IN123041
IN152011
IN077061
1N077071
IN151051
IN083021
IN101031
IN092031
1N043031
IN087021
IN074051
IN081021
IN087011
IN110031
IN111021
IN097021
IN101041
IN050021
INI 28011
IN096031
IN060031
IN022041
IN154011
IN020011
IN018021
IN015021
IN009051
IN009061
IN019021
1N008051
93
93
94
92
93
92
92
94
93
94
93
91
92
94
94
92
93
93
93
94
93
93
93
92
93
93
93
94
94
92
92
92
92
93
93
94
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
IN
Z-AZIE
Afkorting org.
CHAI
CNI/SBSS
CTVT
VHAI
SEDS
RVHA
VHAI
VHAI
DEEPALAYA
DEEPALAYA
VHAA
SUCH I
VSA
EHA/TUSHAR
CEDMA
JCSS
AGRT
CRDS/CHITTOOR
JCSS
CDT/ASHA KENDRA
KASSAR
SARVODAYA
VSA
CRTDP
SNEHAKUNJA
TBS
CORD
CCD
CSD
CUS
RHDC
TGBK
ANTARA
ANTARA
CIN1
TSRD
Beh.
AVON
AVON
AVDM
AVON
AVON
AVDM
AVDM
BR
BR
BR
BR
MV
MV
MV
MV
MV
MV
MV
MV
MV
MV
MV
MV
NOG_
PG
PG
PG
HVDH
HVDH
HVDH
HVDH
HVDH
NVOV
NVDV
NVDV
NV IV
Naam aanvraag
Bedrag finane.
CMAI - ROUND TABLE FINANCING 1993-1996
CNI/SBSS People's Plan 1993-1996
Integrated Community Dev. Pr. Kanumolu
Interim Support to VHAI-Programme
SEDS - socio-eco. dev. of the poor in mi
Steun aan Rajasthan Voluntary Health Ass
VHAI PROGRAMME FINANCING 1992-1995
Community Health Programme 1994 - 1997
Deepalaya Fund Raising 1993-1995
Interim South Delhi/Phase-in/Core 94-95
Vhaa Community Health Prograame 1993-199
Community Development Programme
Community Health Programme 1992-1993
Community health, education & dev. pro.
Community organization and dev. pro. 94Comprehensive Dev. Project of Weaker Sec
Consortium Project 1993-1996
CRDS Community Development Project 1993Interim Development Project 1993/94
Interim health and education programme 9
Kassar Trust People's Water, Sanitation
SA Integrated Development Programme
VSA Community Health Programme 1993-1996
Comprehensive Tribal Dev.Project - Inter
Rural Health and Development Programme 1
TBS/IREDP Integrated Rural Education and
Tribal Socio Economic Development 1993-1
CCD-Community Dvpt Programme in Rural Ar
CSD-Urban Development Project, April 94CUS - Urban Programme, 1992-1995
RHDC - Rural Health & Development Projec
TGBK-Comm. Health i Women Development Pr
AANKOOP GROND T.B.V. UITBREIDING PSYCH.C
ANTARA - SUPPL ETIE ONDERHOUDSKOSIEN
CINI-SUPPORT TO THE INT.DEV. PROGR. FOR WO
TSRD - Patamda Interim ,9,’4
Fin. per.
518.303,00
1.251.141,00
147.859,00
78.100,00
111.575,00
122.482,00
328.500,00
38.965,00
118.525,00
243.167,00
132.620,00
93.648,00
10.568,00
78.544,00
154.579,00
23.426,00
574.837,00
212.810,00
34.143,00
177.208,00
158.885,00
138.760,00
175.877,00
42.163,00
134.275,00
219.398,00
1.196.115,00
161.163,00
98.794,00
143.626,00
6.344,00
23.960,00
59.265,00
59.000,00
179.089,00
187.212.00
Omschrijving aard organisatie
9304-9603
9304-9603
9404-9803
9204-9209
9307-9403
9204-9303
9210-9503
9404-9703
9301-9512
9401-9503
9310-9609
9201-9412
9207-9307
9406-9605
9208-9303
9304-9603
9302-9601
9304-9403
9404-9503
9304-9603
9307-9606
9307-9607
9208-9307
9304-9603
9306-9605
9304-9603
9404-9703
9404-9603
9207-9506
9207-9306
9207- 9306
9208- 9303
9206-9306
9309-9608
9403-9506
Percentage
Ne twerkorgan i sa t i e
Dienstverlenende organisatie
Dienstverlenende organisatie
Ne twerkorgan i sa t i e
Intermediaire organisatie
Dienstverlenende organisatie
Ne twerkorgan i sa t i e
Ne twerkorgan i sa t i e
Intermediaire organisatie
Intermediaire organisatie
Dienstverlenende organisatie
Dienstverlenende organisatie
Dienstverlenende organisatie
Intermediaire organisatie
DoeIgroep/Bas i sorgan i sat i e
Dienstverlenende organisatie
Dienstverlenende organisatie
DoeIgroep/Bas i sorgan i sa t i e
Intermediaire organisatie
Dienstverlenende organisatie
Intermediaire organisatie
Dienstverlenende organisatie
Dienstverlenende organisatie
Intermediaire organisatie
DoeIgroep/Basisorganisatie
Intermediaire organisatie
DoeIgroep/Bas i sorgani sati e
Intermedia!re organisatie
Intermedia!re organisatie
Intermediaire organisatie
Intermediaire organisatie
80,00
10,00
10,00
100,00
40,00
70,00
100,00
40,00
15,00
10,00
100,00
50,00
30,00
60,00
35,00
20,00
100,00
20,00
30,00
50,00
10,00
30,00
90,00
30,00
100,00
30,00
15,00
38,00
35,00
40,00
40,00
60,00
100,00
100,00
100,00
18,00
\T)
X
Kluster
Pro.nr.
Pr.jr.
Z.Azie
IN 008
93
India
IN 157
India
LvU
Afk. org
beh.
Naam aanvr.
IN
TSRD
NvdV
TSRD-Core Pro. 93-96
89
IN
ACHAN
BR
ACHAN
IN 040
91
IN
AF
India
IN 057
91
IN
India
IN 035
92
India
IN 094
India
bedr. fin.
Fin.per
Om.aard.org
%
731.600,-
93.12
Inter
mediair
10
Pro. 89-92
269.240,-
89.10
Netwerk org
100
BR
AF Eco-employment
programme 91-93
2.273.798, -
91.07
Inter
mediair
10
ASSEFA
BR
ASSEFA Integrated
Rural Devt. Projects
4.195.145,-
91.04
Inter
mediair
5
IN
AWARE
BR
AWARE Interim
Perspective Plan
5.46.997,-
92.10
Inter
mediair
10
92
IN
DOS
BR
ADATS/DDS Extension
Prog. Phase II
1.594.125,-
92.07
Inter
mediair
10
IN 055
91
IN
GV
BR
Gram Vikas
Gezondheidszorg +
Milieu
3.781.900, -
92.01
Inter
mediair
10
India
IN 073
94/91
IN
INSA
BR
Rural Health + Dev.
Trainees Pro.
1.10.057,-
91.03/
95.03
Inter
mediair
100
India
IN 101031
92
IN
VSA
MV
Community Health
Programme 92-93
10.568,-
92.07/
93.06
Inter
mediair
90
ANNEX 3: SELECTED STATISTICAL DATA ON INDIA
A.
General geographic and demographic indicators
Total land area:
Population (1991):
Male population:
Female population:
Rural:
Urban:
Sex ratio (females per 1000 males):
rural:
urban:
Population under 14 years (as a
percentage of the total population):
Average growth rate (1981-1991):
Decadal growth rate (1981-1991):
Density of population (1991):
Population projection (year 2001):
Religions (percentage of population):
Hindus:
Muslims:
Christians:
Sikhs:
Buddhists:
Jains:
Scheduled castes and tribes (as a
percentage of the total population):
Total literacy rate (1991):
Male literacy rate:
Female literacy rate:
Ruralr for males:
Rural, for females:
Urban, for males:
Urban, for females:
B.
3.288.000km2
846,3 million
439,2 million
407,1 million
628,7 million
217,6 million
929
941
893
40%
2,1%
23,6%
267 persons per km2
1.003.000.000
82, 6%
11,4%
2,4%
2,0%
0,7%
0, 5%
24, 6%
52,2%
64,2%
39,2%
57,8%
30,4%
81,1%
63,9%
Some health indicators
Crude birth rate (per 1000 pop.):
1951:
1992:
Crude death rate (per 1000 pop.):
1951:
1992:
Life expectancy at birth (1986-1991):
Male:
Female:
Infant mortality rate (per 1000
life births):
1971:
1991:
Urban:
Rural:
(51,7%)
(48,3%)
(74,3%)
(25,7%)
39,9
29
27,4
10
58,1
59,1
129
80
53
87
Under five child mortality (per 1000
children):
1984:
1988:
Maternal mortality rate
(per 100.000 births, 1983):
C.
500
Urban population
The four largest cities:
Bombay:
Calcutta:
Delhi:
Madras:
Total urban population (1991):
Urban population as % of total:
Decadal growth rate (1981-1991):
Average annual growth rate:
Number of million-plus cities:
D.
21z2
13,3
12,6 million
10,9 million
8.4 million
5.4 million
217 million
25,7%
36,19%
3,09%
23
Economic indicators
GDP per capita:
Growth of GDP 1980-1991:
Share of the three major sectors
in GDP:
Agriculture:
Industry:
Services:
Number of middle class population:
Average annual inflation 1980-1991:
Total external debt (millions US $):
1980:
1991:
US $330
5,4%
30%
30%
40%
150 million
8,2%
20.611
71.557
AMM'ex
of thQ
th Situation in fid a
HEfiLTH STfiTUS IN THE fiSJfiN REGION “ 1990
TABLE - 2
Coun t^ries
•
IMR
1990
Under 5
Morta1i ty
Rate
Life
Crude
Death
E>: pec —
tancy
Rate
at birth
(years >
1990
Crude
Birth
Rate
Ma terna1
Tota 1
Morta1i ty popu
Rate
lation
(Millie
1. Afghanistan
167
292
43
23
51
640
16.6
2. Cambodia
123
193
50
16
39
500
S.2
3. Bhutan
123
1S9
49
16
39
1310
1.5
4. Nepal
123
199
52
14
39
930
19.1
5. Bangladesh
114
190
52
15
41
600
115.6
6. Paki s tan
104
158
58
12
44
500
122.6
7 . Laos
104
152
50
16
45
9.
India
94
142
59
11
32
460
853.1
9.
Indonesia
71
97
61
9
29
450
194.3
10.Myanmar
65
89
61
9
30
460
41.7
11.Mongo 1ia
64
84
63
8
35
140
2.2
12.Philippines
43
69
64
7
32
100
62.4
13.Vietnam
49
65
63
9
31
120
66.7
14.China
30
42
70
7
21
95
1139.1
15.Korea, Dem
26
35
70
5
24
41
21.9
16.Sri Lanka
26
35
71
6
22
80
17.2
17. Thai 1 and
. 26
34
66
7
21
18.Korea. Rep
23
30
70
6
16
26
42.8
19.Malaysia
22
29
70
5
30
59
17.9
20.Singapore
8
9
74
5
17
1.0
2.7
21.Hongkong
7
7
77
6
13
6
5.9
22.Japan
5
6
79
7
11
11
123.5
Sourc
L-O o -r I d l~f c*. I
S’ K'C
Zir-? rr l_* e* /
4.1
55.7
G. -r’C^. t I
Tabic 1.13
Birth Rate End Dcftfo Rate
(Three-year moving average)
Death rates (per ’000)_________
Birth rates (per ’000)
1971-73 1974-76 1979-81 1984-86 198W1
1971-73 1974-76 1979-81 1984-86 1989-91
34.1
35.8
36.0
32.3
25.4
30.5
na
na
21.3
22.4
34.7
34.1
31.9
40.9
na
31.2
31.8
35.5
na
31.3
30.2
33.8
32.0
43.2
na
41.7
29.6
13.0
10.8
9.8
8.8
WJ
12.4
U3
11.2
9.7
9-3
9.0
8.6
Kerala
Madhya Pradeah
Maharashtra
8.9
17.1
8.1
6.8
6.3
6.0
16.9
15.7
14.0
13.1
10.0
7.9
6.5
8.7
6.9
7.8
Manipur
11.4
7.0
10.5
11.5
6.2
10.1
19.1
31.6
UM
14.6
22.9
37.9
33.3
28.3
28.7
323
9.0
12.6
10.7
9.6
29.6
36.0
29.3
25.0
12.4
11.0
Karnataka
32.9
37.9
35.1
36.8
31.1
31.0
14.6
27.5
37.6
37.5
7.7
304
38.6
40.6
26.0
8.0
Himachal Pradesh
Jaman A Kashmir
38.4
27.6
38.9
10.8
15.7
38.1
20.5
29.3
24.0
30.5
38.6
14.4
Gujarat
Haryana
32.9
30.7
13.9
9.3
31.9
36.7
34.7
313
28.0
10.4
15.3
13.0
8.8
33.1
3K2
28.4
11.7
15.4
11.5
14.7
7.1
14.9
22.8
16.2
13.5
31.6
17.7
States
Andhra Prade*h
Arunachal
Pradeah
32.1
Assam
29.3
Bihar
32.6
Goa
16.0
15.8
20.9
17.3
15.7
34.2
32.2
30.9
36.0
30.0
27.7
37.5
23.7
32.0
25.8
28.6
33.4
27.7
36.1
27.4
Meghalaya
ni
18.1
Nagaland
na
9.0
6.9
6.7
3.7
29.7
2*.2
Oritsa
17.9
15.1
14.0
13.8
12.3
8.7
8.0
Punjab
Rajasthan
37.1
na
38.6
32.3
33.9
28.1
Sikkim
28.3
26.9
39.5
32.5
25.5
27.5
38.0
29.8
22.1
24.9
35.9
27.1
Tamil Nadu
Tripura
Uttar Pradeah
West Bengal
31.1
28.1
33.8
36.8
23.9
34.7
26.7
Included under Goa
42.1
34.6
38.9
31.1
28.9
27.3
20.5
18.1
34.0
27.7
24.7
35.9
29.2
37.7
28.9
31.0
24.8
34.9
23.3
36.3
34.4
33.8
35.3
33.0
31.6
38.7
37.9
35.3
36.9
8.4
ni
29.1
na
12.9
11.0
21.1
31.8
29.6
35.2
11.3
93
Union Territoriea
Andaman
Chandigarh
16.2
na
15.0
9.2
13.5
13.1
10.0
na
na
10.9
9.0
14.5
14.5
11.7
9.9
8.7
13.4
10.5
20.9
12.4
9.1
16.4
9.9
16.1
9.7
11.9
8.3
11.7
21.7
na
10.8
11.3
7.7
5.8
4.0
Dadra & Nagar
Daman A Din
Delhi
14.8
7.8
7.8
8.1
4.4
2.6
4.3
Included under Goa
12.3
15.4
13.5
8.0
6.9
7.6
27.2
20.0
Lakshadweep
Pondicherry
14.5
9.5
11.6
10.5
9.8
7.1
8.3
8.0
5.4
7.1
33.2
29.9
All-India
15.9
15.0
12.7
11.8
10.1
31.7
29.6 Relatively rich Statea
12.0
11.6
16.3
10.1
9.0
8.1
14.9
14.3
11.6
36.9
33.6 Relatively poor Stataa
8.0
17.7
8.4
10.1
8.7
6.3
LIST OF 90 DISTRICTS WITH POOR DEMOGRAPHIC PROFILE
District
State
State
District
BIHAR
1
2
3
4
5
44
45
46
47
48
49
50
51
52
53
54
55
56
NAWADA
SAHARSA
SAMASTIPUR
KATJHAR
GAYA
GUJARAT
6 KACHCHH
7 BANASKANTHA
HARYANA
KERALA
8 BHIWANI
9 malappuram
MADHYA PR.
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
SEHORE
REWA
GUNA
DAMOH
GWALIOR
PANNA
RAI SEN
HOSHANGABAD
VIDISHA
TIKAMGARH
BHIND
WEST NIMAR
SAGAR
JHABUA
BHOPAL
SHIVPURI
BETUL
CHHATARPUR
MORENA
EAST NIMAR
DATIA
DHAR
SATNA
UTTAR PR.
57 FARRUKHABAD
58 PRATAPGARH
59 MAINPURI
60 BANDA
61 AZAMGARH
62 SHAHAJAPUR
63 TEHRI GARHWAL
64 HARDOI
65 MORADABAD
66 ALIGARH
67 LALITPUR
68 PILI PH IT
69 DEORIA
70 BULANDSHAR
71 GORAKHPUR
72 BUDAUN
73 SHARANPUR
74 SITAPUR
75 BASTI
76 SULTANPUR
77 ETAH
78 JAUNPUR
79 AGRA
80 BAREILLY
81 GONDA
82 ALLAHABAD
83 NAINITAL
84 MEERUT
85 BIJNOR
86 RAEBERELI
87 GHAZIABAD
88 RAMPUR
ORISSA
33 BALESHWAR
RAJASTHAN
34 JODHPUR
35 UDAIPUR
36 SAWAI MADHOPUR
37 KOTA
38 JHALAWAR
39■JALOR
40 DUNGARPUR
41 BHARATPUR
42 BANSWARA
43 AJMER
SI ROH I
GANGANAGAR
JAIPUR
SIKAR
BIKANER
PALI
BARMER
ALWAR
BUNDI
NAGAUR
JHUNJHUNUN
TONK
CHURU
WEST BENGAL
89 MALDAH
90 MURSHIDABAD
Table 2.3
Expenditure on Health: 1950-51 to_1992_23
(Ra. crore»)
Private final
conaumption expenditure
Rs. Per
crore
capita
Combined Government Expenditure
Family Welfare
Medical, Public Health
Sanitation, etc._______
Revenue
Capital
Revenue
c-pit^r
Total
Expen
diture
Per
person
(R>.)
27.9
0.3
28.2
0.79
1950-51
50.9
2.1
52.9
1.35
1955-56
4.81
88.9
8.8
2.29
205
97.7
1960-61
1961- 62
1962- 63
1963- 64
1964- 65
1965- 66
227
253
296
345
390
5.11
5.57
6.38
7.28
8.04
168.5
11.2
179.7
3.70
1966- 67
1967- 68
1968- 69
472
505
536
9.54
9.98
10.35
1969- 70
1970- 71
1971- 72
1972- 73
1973- 74
565
618
727
854
1,004
10.68
11.42
13.12
15.06
17.31
305.4
330.1
391.0
477.1
490.1
15.5
19.7
27.9
38.7
41.7
320.9
349.8
418.9
515.8
531.8
6.07
6.47
7.56
9.10
9.17
1974- 75
1975- 76
1976- 77
1977- 78
1978- 79
1,180
1,386
1,629
1,915
2,221
19.90
22.83
26.27
30.21
34.27
555.2
628.2
715.8
831.1
973.1
63.7 ■
78.5
104.1
119.1
132.3
65.7
85.9
171.0
95.8
107.8
3.0
3.5
1.8
1.2
2.7
687.5
796.1
992.7
1,047.2
1,215.8
11.59
13.11
16.01
16.52
18.76
38.81
1,154.6
166.3
119.1
2.8
21.73
2.577
1,442.7
1979-80
1980- 81
1981- 82
1982- 83
1983- 84
1984- 85
2,970
3.451
4,014
4,666
4.829
43.74
49.76
56.61
64.45
65.35
1,389.9
1,652.3
1,925.8
2,306.1
2,624.7
227.8
276.1
318.2
396.4
402.9
141.9
183.2
273.1
359.5
392.3
4.4
9.0
21.4
32.7
36.6
1,764.0
2,120.5
2,538.5
3,094.5
3,456.5
25.98
30.55
35.80
42.74
46.77
1985- 86
1986- 87
1987- 88
1988- 89
1989- 90
5,089
5,355
5,923
7,264
7,604
67.40
69.46
75.16
90.24
92.51
3,042.5
3,580.2
4,148.9
4,674.5
5,282.1
426.4
487.8
595.1
599.9
512.0
484.5
529.0
601.1
676.1
803.1
52.0
41.3
41.1
36.8
64.2
4,005.5
4,638.2
5,386.2
5,987.4
6,661.5
53.05
60.16
68.35
74.38
81.04
1990- 91
1991- 92
1992- 93
8,242
9,022
98.35
105.40
5,705.0
617.4
859.0
102.8
7,284.2
8,201.1
8,878.0
86.92
95.81
101.70
Table 2,1
Health Services: 1960 to 1990
Registered doctors
Lakh
Per lakh
persons
Hospi
tals
Dispen
saries
Primary
health
centres
Subcentrea
Beds(b)
’OOO
Per hkh
popu
lation
(«)
(«)
1960
0.76
17.6
4,011
9,874
2,800
200
46
1965
1.00
20.7
3,900
9,486
4,481
295
61
1970
1.39
25.8
4,239
10,508
5,112
28,489
326
60
1975
1.98
33.0
4,023
11,295
5,328
34,088
404
66
1980
1981
1982
19S3
1984
2.55
2.69
2.72
22_34
2.97
37.2
39.2
39.6
-41-5
43.2
6,670
6,804
6,897
TJ89
7,369
15,968
16,751
17,409
31,777
21,872
5,740
5,851
5,959
3375
7,284
51,405
57,975
65,643
TL236
84,590
561
569
584
399
625
82
81
82
X2
84
1985
1986
1987
1988
1989
1990
3.08
3.20
3.31
44.8
46.6
48.2
7,474
8,067
9,834
10,156
10,157
25,584
26,943
27,728
28,841
28,565
12,934
14,281
16,449
18,811
20,531
22,229
92,483
101,549
109,644
120,767
129,291
131,379
657
695
719
741
750
86
90
93
92
93
Compound annual rate of increase (%) between
3.1
I960 & 1990
5.6
3.8
3.6
7.1
7.9
4.7
2.5
3.65
(a) Relates to financial year e.g. 1960 refers to 1960-61.
(b) Includes all types of beds in hospitals,dispensaries,PHCs snd voluntary organisations.
Distribution of Hospitals and Dispensaries:! January 1990
Dispensary beds
Hospital beds
Dispensaries
Hospitals
%
Number
%
Number
%
Number
%
Number
Government
4,178
41.1
9,702
34.3
403,577
67.0
15,191
66.3
Local bodies
348
3.4
2,937
10.4
21,830
3.6
1,772
7.7
5,646
55.5
15,665
55.3
177,083
29.4
5,965
26.0
100.0
59.5
40.5
Pvt. &
voluntary
Total
Rural
Urban
10,172
100.0
28,304
100.0
602,490
100.0
22,928
3,167
7,005
31.1
68.9
12,747
15,557
45.0
55.0
95,722
506,768
15.9
84.1
13,642
9,286
Per lakh population
Rural
Urban
0.51
3.23
2.03
7.16
15.26
233.32
2.18
4.28
67/ £
NATIONAL NORMS
1. Atleast one trained dai
2. One trained Village Health
Guide....................
3. One Sub-Centre
4. One Prleary Health Centre(PHC)
5. One Coeeunity Health Centre(CHC)
6. Sub-Centres Covered by a PHC
7. PHCs Covered by a CHC
for each village.
for each v i11 age/
1000 populat i on.
for every 5000 population in plain area 4
for 3000 population
in tr iba 1 , and hilly
areas.
for every 30,000 popula
tion in plain area 4
20,000 population in hilly,
and tribal areas.
for every 80,000 to 1.20
1akh population,
serving as a referral
institution for four
Primary Heal th Centres.
& Sub-Centres
4 PHCs
8. Population covered by a
Health Worker (Male 4 Fewale)
i) 5000 in Plain area
ii) 3000 in tribal and
hilly areas .
9. Population covered by a
Health Asstt. (Male 4 Female)
i) 30,000 in Plain area
ii) 20,000 in tribal and
hilly areas .
10. One Health Ass11. (Hale/Fe*ale)
Provides supportive
supervision to 6 Health workers
(Maie / Fewale)
6 health Workers (Maie/Female)
STATEMENT -I(Contd)
3.3 (a) PHCs with 4 without Doctors
PHCs
with 4
or more
Docts.
PHCs
with 3
Docts.
PHCs
with 2
Docts.
PHCs
with 1
Docts.
PHCs
without
Docts.
(1)
(2)
(3)
(4)
(5)
408
716
4059
6874
1115
3.3 (b) PHCs without Lab. Tech/Pharmacist
PHCs
Lab.
(6)
(7)
6045
750
4.0 ANM/HW(F) as on 31.3.94
wiihi
1.
2.
3.
PHCs without
Pharmacist
without
Tech.
ii
-466
20291
Total number of ANM Schools
Annual admission capacity
Average Annual admission
capacity per School
43 (Approx.)
4.1 LHV/HA(F) AS ON 31.3.94
1.
2.
3.
44
2758
LHV/HA(F) promotional schools
Annual admission capacity
Average Annual admission
capacity per Scfcool
63 (Approx.)
5.0 HEALTH MAN POWER IN RURAL AREAS As °n 31.3.94
t
No.
Sanctioned
No. In
Position
Vacant
1. Surgeons
2. Obst. S Gynaecologists
3. Physicians
4. Paediatricians
5. Doctors at PHCs
6. Block Extension Educators
7. Health Assistants (Male)
8. Health Workers (Male)
9. Health Assistants (Female)/LHV
10. Health Workers (Female)/ANMs
11. Pharmacists
12. Lab Technicians
13. Nurse Mid-wives
14. Radiographer
1053
816
667
628
27621
6246
20108
70259
21629
131904
20438
12233
14915
1185
725
421
464
340
23672
5782
18564
62200
20127
124365
18644
9804
11583
972
31.1
48.4
30.4
45.9
14.3
7.4
7.7
12.8
6.9
5.7
8.8
19.9
22.3
17.9
Actual Total of catagories (i)-(4)
S= 3891
P = 2598
t V= 33.2
Category
7
^7 / £S
'-Rlr-IRRy
/iERLTR
STAFFING
A
STAFF FOR SUB-CENTRE
1
Health Worker(Fernale)/ANM
C- E
r R E '3
PATTERN
No. of Posts
1
2. Health Worker(Male)
1
3. Voluntary Worker (Paid 9 Rs.50/-p.m.as honorarium)
1
3
B. STAFF FOR NEW PRIMARY HEALTH CENTRE,. *
1 . Medical Officer
1
2. Pharmacist
1
3. Nurse Mid-wife (Staff Nurse)
1
4. Health Worker (Female)/ANM
1
5. Health Educator
1
6. Health Assistant (Male)
1
7. Health Assistant (Female)/LHV
1
8. U.D.C.
1
9. L.D.C.
1
10.Lab. Technician
1
11.Driver (Subject to availability of
vehicle)
1
12.Class IV
4
15
* for every 30,000 population in plain area &. 20,000 population
in tribal and hilly areas.
57' r
Table 2.1
Family Planning Programme during 1991-92
_________________________ ('000 numbers)
Couple
protection
rates (%)
(31.3.91)
Cumulative Acceptors aince inception
Sterilij IUD
Per ’000 population
inser
Sterili
Mtioa
IUD
tions
sation
inser
tions
Number of Acceptors during 1991-92
Sterili
IUD
Convmtiontl
Ord
sation
inser
cohtr>cepdve
pill
tions
users
users
States
44.3
8,088
1,914
121.6
100.8
Andhra Pradesh
483.5
290.1
790.9
10.5
11
21
13.1
7.8
Arunachal Pradesh
1.8
2.2
1.2
1.2
28.2
1,585
445
70.7
62.2
Assam
66.3
28.3
38.5
11.8
26.0
5,877
2,130
68.0
58.6
Bihar
212.6
134.3
105.3
35.7
34.0
77
33
65.7
54.6
Goa
4.1
3.5
14.7
2.2
57.8
5,146
3,280
124.6
106.8
Gujarat
257.3
348.8
776.6
114.2
56.6
1,605
2,114
80.5
Haryana
100.8
147.0
487.8
36.6
52.1
-572
3«3
97.5
110 6
90.6
Hinwhil Prwdnt
3X.1
-CA
196.1
21.1
421
222
54.6
43.6
Jammu &. Kashmir
38.1
10.5
10.8
3.8
46.9
4,840
2,253
107.6
88.2
Karnataka
301.6
233.4
255.3
83.4
55.6
3,574
1,234
122.8
103.2
Kerala
173.6
115.4
296.4
39.0
40.3
6,084
2,833
91.9
79.2
Madhya Pradesh
316.6
322.6
1,028.6
262.9
56.2
11,234
4,976
142.3
121.8
Maharashtra
538.1
467.9
1,089.5
379.8
41.0
71
80
38.4
31.8
Manipur
4.0
5.5
2.7
0.1
5.0
20
20
11.0
10.1
Meghalaya
0.6
1.8
1.4
1.2
41.4
41
22
59.1
41.5
Mizoram
4.5
2.0
2.4
1.1
4.8
8
7
6.8
4.1
Nagaland
1.0
0.6
0.0
0.1
41.0
3,259
1,525
IG2.9
89.2
Orissa
137.3
149.3
267.9
61.5
75.8
1,971
3,760
97.2
81.6
Punjab
85.5
358.6
537.8
72.1
29.0
2,875
1,486
65.3
55.2
Rajasthan
173.3
158.6
375.5
60.2
20.6
10
14
25.2
17.4
Sikkim
57.3
7,835
3,470
140.3
120.0
Tamil Nadu
1.3
0.9
0.4
2.1
364.5
431.8
290.9
157.2
17.6
113
22
40.9
32.5
Tripura
7.6
2.5
2.7
3.5
35.5
7,784
11,352
56.0
46.6
Uttar Pradesh
375.8
833.5
1,609.5
251.9
33.7
5,926
1,412
87.0
72.8
West Bengal
327.1
168.2
342.6
131.0
42.3
21
17
75.8
54.6
Andaman
1.9
1.8
2.4
0.6
41.8
47
92
73.7
61.7
Chandigarh
3.0
6.0
18.6
0.3
47.5
16
2
114.1
96.8
Dadra & Nagar
0.8
0.3
0.5
0.1
30.2
40.4
4
40.1
28.4
Daman & Diu
0.4
0.2
0.9
0.1
632
1
877
67.1
56.2
Delhi
37.2
78.1
363.2
8.0
1
60
17.7
16.4
Lakshadweep
0.0
0.1
0.2
0.1
60.6
1
113
139.6
110.5
Pondicherry
8.2
4.2
11.8
1.0
44.1
80,873
46,435
95.6
80.9
AH-India
4,116
4,384
14,019
3,369
34.4
U.810
25,879
UMS I
19,326
128.0
70.5
108.9 Relatively rich States
60.0 Relatively poor States
724
1,216
1,216
973
1,598
705.0
488
677.3
672
Union Territories
8.6
AH'India includes
•cceptora in defence Sc railways and oral pills and CC distributed commercially.
APPENDIX-III
targets AND ACHIEVEMENTS UNDER MCH PROGRAMME DURING 1992-93
(Figures inOOO’s)
Achieve
ment*
1992-93
2.
3.
4.
Tetanus Immunisation
for expectant mothers
27008
21444
79.4
DPT Immunisation for
children
24290
21907
90.2
iii. Polio
24290
22058
90.8
iv.
B.C.G.
24290
23430
96.5
v.
Measles
24290
20830
85.8
vi.
DT Immunisation
for children
17552
12906
73.5#
vii. T.T. (10 years)
16054
10448
73.1#
viii. T.T. (16 years)
16102
8249
57.5#
27008
24290
16296
13889
60.3#
57.2#
24290
28429
(doses)
66.4#K
1.
ii.
C.
of
Annual
target
of 199293
Immunisation
A.
B.
%Achvt.
Target
for
1992-93
Activity
Prophylaxis against
Nutritional Anaemia
among:
(a) Total women
(b) .Children
Prophylaxis against
Blindness due to Vit.A deficiency
* Figures provisional.
K
of achievement of target was worked out by taking half of the total doses given to the
first time initiated continuing and completed dosed beneficiaries as annual target of
Vitamin ’A’ solution are two dosed beneficiaries.
Worked out after excluding targets for States/UTs for which achievement figures were
not received.
6&/ a
TAMf
SL.
VC.
'
fjuttaif fOi FMUOl WWMtl
aMTtct'or
corw* ICABLE Ol UAW* PWOCMA^ O4J«I»C
SEVENTH PLAN 1985 • 90
IMDEX
NAME OF THE SCHEME
3
2
1
1.
Malaria Control Programme
2.
National Leprosy Eradication
Programme.
3.
4.
Control of Blindness.
T.B. Control Programne.
(a) Annual parasite Index
(b) Deaths recorded and verified
(a) Cases detected
(b) Cases put on treatment
(c) Cases discharged
(a) % of Blindness
(a) Total No. of cases detected as
X to total estimated cases.
(b) Disease arrested cases.
Population under Protection.
5.
Filaria Control Programme
Source : Respective Programme
Officers.
CURRENT
POSITION
TARGET SET FOR
1985-90 PLAN
4
5
2.16 (1990)
(1990)
222
24.46 lakhs
23.72 lakhs
27.98 lakhs
1.9
Nil
19.62 lakhs
19.62 lakhs
24.47 lakhs
1.4
%
0.5 %
42
%
50 %
70 %
66
42.60
mi 11 ion
45 million
TABLE 1
Current stock. Annual otturn, supply, total stock, projeted requirements and gap regarding health manpower at Primary and
intermediate level of care i.e. upto level of Community Health Centre.
S.No.
1
1986
IAN
1991
2000
2
3
4
5
6
7
8
2,902
505
61,428
14,437
4,922
1,124
196
14,228
5,593
1,907
35
617
8,533*
4,063
1,558
609
175
3,702
51,198
20,315
9,348
4,872
490
9,255
127,995
56,882
23,377
10,353
3,077
4,207
112,626
34,752
14,270
4,872
1,614
9,451
142,223
62,475
25,277
10,353
5,548
2,149
627
3,135
8,778
8,683
10,927
9,441
15,415
49,673
56,460
3,658
5,972
19,244
21,874
1,538
3,095
819
15,296
7,690
15,475
4,095
76,480
21,532
17,131
30,890
53,768
132,940
25,190
49,302
30,710
236,018
1. Community Health
Officer
2. Block Extension Educator/
4,915
Health Educator
3. Opthalmic Asstts.
951*
162,875*
4. Staff Nurses t
5. Pharmacist
24,449
6. Lab. Technician
8,336*
7. X-Ray Technician/
INA
Radiogrpher
9,395
8. Nurse Midwife
9. Dreasser
651
10. Health Asstt. (M)
15,989
11. Health Asstt. (F)
26,105
12. Health Worker (M)
84,122
13. Health Worker (F)
95,615
14. Health Gnjde**
385,572
15. Traditional Birth**
515,691
Attendant (TBA)
Stock in
1981
200O
1991
9(4 I 7)
43,330
11,466
214,144
Gap
Requirement
•Total Stock
Supply by
Annual
-x outturn
1983
Category of Manpower.
2000
1991
2000
11
12
13
14
22,305
28,578
6,273
409,246
34.851
34,851
6,273
26,439
33,875
7,436
664,623
41,511
41,511
7,436
25,501
2,066
296,620
99
20,581
1,401
32,261
(-)2.015
522,400
(—)20,964
16,234
(-)3,U7
66,216
6,273
34,155
34,155
136,620
158,925
627,337
627,337
78,491
7,436
40,485
40,485
161,941
188,380
743,610
743,610
57,533
87,564
2000
1991
10(5-1-8)
17,024
15,295
(-)8,817
3,265
131,231
82,852
25,985 • (-)47,638
* Figures pertain to the year 1985.
** Being Voluntary workers, calculations cannot be done in the same manner as is applicable for other workers,
t Calculations are based on manpower requirement for hospital nursing services.
fNA Information Not Available.
tJ The
The gaps
gaps indicated
indicated above
above arc
are only
only in relation to the need of Primry and Intermedite Health care services. These will become much wider when viewed in the perspective
of comprehensive health care system including tertiary care services, as also the needs of organized sector and private sector.
§ The requirements indicated above are only In relation to the needs of primary and intermediate health care services. A large number of the surplus will be absorbed by
the organised sector and t he private sector.
<A
Position: 2659 (2 views)