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2

The background

The Health Departeent of the Central Tibetan Secretariat at Dhamsala
got in touch with the Comunlty Health Cell in August 1988, as a follow
up to a reccmnendation made by Dr Prem chandran John, Coordinator of Asian
Community Health Action network (ACHAN) and Consultant to BREAD FOR THE
/DRW, a funding agency that supports the Tuberculosis Programme and
Primary Health Care activities in the Tibetan Settlements in Karnataka
State,
After a preliminary phase of communication, in which the principles of
Community Health Cell involvement (outlined in the preamble) were
explored, it was decided to old a •brainstorming session at the
Community Health Cell along with representatives of the Health Pepartoent
and the Medical Officers of the Tibetan Settlements.

The Process
This session was held at the Cojemunlty Health Cell on 10 November 1988.
Mr Thupten Phuntsok, Deputy secretary to the Department of Health and
Drs Pas ang Horbu and Tsewang Hgodup of the Mundgod and Koi legal
settlements attended . The Community Health Cell team consisted of

3

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7

OE.FRVATICKS

RECC.Vr'EmiATIOKSAOSSIBLE ALTERNATIVES FOR ACTION

c. Administration and funds
The budget of the hospital
is prepared by a Committee
consisting of the Representative
of the Settlement, Village
traders and the Medical Officer.

About 25% of the funds are met
by the Health Tax, Bed Charges and
opr charges at present. Free
treatment is given to deserving
patients*
It is proposed to collect further
25% from the same resources.
This con-unity participation will
meet a major part of th® health
budget apart from TB control
programs.
decisions are made with the
participation of the community
(represented by the leaders)
with adequate flexibility for
tiie medical officer*a functioning
in medical matters.

»

8
OBSERVATIONS

The percentage of patients
on second line anti—tubercsil ar
treatment showed 35.0% in 1985j
32.1% in 1906; 36.2% in 1987
and 28.68% in 1988 (upto Nov.}
The cause for this is the
starting of second line
treatment at private clinics
and other centres which <jo not
follow the National Tuberculosis
Prograinme recore; endec regime. A
standard treatment policy in
all the settlements in
accordance with the National
Tuberculosis programme is
being implemented.
From the statistics prcvidec,
it is noticed that more t±i«n
31% of the proposed budget for
TB and Primary Health Care
programme is earmarked for
anti-tuberculosis drugs in view
of the hich proportion of cares
being on costlier second line
treatmwit, and the inability
of the District Tuberculosis
Centre tc supply these drugs.
This cost is despite the fact
that all other health care
activities are being met by the
community itself.

R>-a3MHEKnATI0NS/POSSIBLE ALTtRKATIVES FOR ACTION
1. Ensuring that all Tibetan Settlers
approach their own health centres
or the nearest District Tuberculosis
Centre to enable the standard
treatment policy to be followed.
2. Consider mobile health worker with
first line drugs; even if the
diagnosis is made by the private
practitioners, treatment tc be
followed shouxd be as per the
Ratio al Tuberculosis ProgruFsie.
3. Links with local practitioners/
organisations could be established
for following the National Tuberculosis
Frojramme (RTP) regime.

4. Consider training of mobile sweater
sellers for tuberculosis programme.
5. Employer of theswater sellers mey
be requested to take action as in
1-3 above on detection of tuberculosis
cases.

6. Check if second line drugs with
Comprehensive Medical Services-India
(CMS-I), Madras, are cheeper, details
of which are being sent to I'oeguling
Hospital.

7. A goal for eradicating/controlling
(to national leval) the TB problem
should be set.

9

OBSERVATICHS

There- is no definite staff
development and continuing
education programme as a
policy In the south Indian
settlements.

recc’? ee: tig»sAo; Siri,e alters tives for actios

Taking this up as a pol icy natter
will enhance the skills of the tear
In performing their work more
effectively. In addition, regular
monthly meetings of the staff,
di.'scuse ion of hc-clth and related
problems, training of staff not
individually but as a tear, will
further strengthen their team work
towards providing primary health care.

Detailed studies of diseases
incldence/prevalence are not
being done due to lack of
funds for this activity.
II. COMMUKITY HEALTH

a* water Supply and Sanitation

Adequate potable water is
available frets borewells
within walking distance.

Overflow and sullage water can be
utilised for kitchen gardens.

Collection and storage of water
is unhygienic.

Proper health education of the
community In this area is needed.

Sanitary facilities for excreta
and waste disposal are grossly
inadequate.

Propagation of the concept of
atleaet cocnrcurity latrines to be
considered.

...10

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11
OBSEWATIQHS

BECCMW.ENOATIGKS/PCSSI RLE ALTERNATIVES FOR ACTION

appear to be s<5e juate in producing
healthy children, maternal and
child health needs deeper study
especially antenatal practices
in order to foster good traditional
practices.

d. Health workers
The health workers are well
trained, motivated, sincere
and capable of handling
responsibility, especially
in TB control progruHse, They
were giv n adequate on the
spot training by the medical
officer for IB control, MCH care
and Health Education. They are
occasionally utilized in hospital
care in place of nurses In
addition to above.
There are 3 drop outs out of
the original 8 health workers
trained end the replacement
workers are yet to be fully
trained.
The younsjer unmarried health
workers are not well accepted
by the comwnlty yet.

Health workers can be trained to
handle minor ailments and given
scsr-e drugs for it thus reducing
the hospital out-patient load.
Additional work with more incentives
to be considered for health workers
to ensure committed primary he sith
care.
In order to ensure replacement of
staff easily rgular training
pro ,r-vmr>e for health workers could
be organised.
The services of part time health
workers could be considered* they
could be selected from amongst
school teaehers/staff of co-operatives/
staff of handloom weaving centres etc.,
who are likely to be rermannt
residents of the settlements.

...12

(•sqdejSeaed snoiAaxd uf r-opaoo&J
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CT

ssKsiivAcasso

13
OBSEWATIC^S

RIXOmESDATIONS/POSSIBLE ALTERNATIVES FOR ACTION

€• Nunnery

It has 25 residents and is
clean and well maintained*
Adequate water and
sanitation facilities are
provided to it* Since it
is next to the hospital,
the inmates utilise health
services well*
g. Homes for the old# inf inn
apd destitute

They have been provided with
adequate water and sanitation
facilities . However, general
and personal hygiene in the
general section is poor* It
is better in the lawa section*

More con^unity health workerfs
activity especially in the field
of hygiene is required* Participation
of community to be sought to take
care of those who are unable to
help themselves*

h. Tibetan Me< iclne and
Astro Institute
It aims at revival and
popularisation of traditional
system of medicine* According
to the Me leal Officer, its
theoretical principles are
similar to Ayurveda*
Source of medicine is centra
lised at its head quarters
in oharmsala*

Integration of activity with the
allopathic system and more so in
the dir ction of providing primary
health care to be considered*
Imparting sorne skills to health
workers and utilising them would
strengthen their efforts*

It could play an Imp ortant role
••••14

i

14

OBSERVATIONS

No local/herbal/home remedies
propagated which can be
easily made at home.
The institute is staffed by a
senior doctor and two trainee
doctors. They conduct home
visits and treatment on
re<>uest.

RECCMMtKV-‘T10NS/P0SSIHLE ALTERNATIVES FOR ACTION

in taking over of hospital overeload
of out-patients wherever possible*
Comparative clinical trials of
treatment for chronic diseases using
both allopathic and Tibetan systems
can be initiated at the settlement
level.

l.Repre entative of the Settlement

Mr G Choeden was very concerned
about the mobile population of
sweater sellers since

Screening of settlers returning from
their prolonged stay outsi- e to spot
TP cases could be considered.

a. they constitute the
younger populations
b. they are unable to learn
any skillsj and
c. they are the major source
of the tuberculosis
problem.

(other suggestions regarding
TB as in I.c. above)•

Mr Choeden invited us to speak
at a Seminar-cum^^orkshcp on
XNT^GRA.TED I'-EViWPMKvT PI AN
FOR TIBETAN SBTTLFFXMT AT

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n
CBSERVATICKS

RS(X»SS ATXCTSAGS.SIBLE alterkatives for action

comments not coWr- d above
From the available statistics*
the following is noticed*

a. The Crude Birth Rate shows
• decreasing trend in the
settlement population.

A detailed study of these statistics
from hospital and cofr-wnity records
will help In formulating a more
meaningful health programme for the
future, especially since this
settlement has a large monastic
pc ulation and also an old age/destitute
home which may account *or the present
interpretation of statistics.

b. The crude death rate is mainly
due to old age and destitute
hen® accounting for it.

c. The infant mortality, neonatal
mortality, maternal mortality,
and mortality by cause could
not be calculated.
d. The high rate of SCG iraraunization
is due to the fact that all
settlers under 19 years of age
wer- isatruniaed in 1985 and more
newcomers into the settlement.

e. The In-patient and out-patient
attendance has decreased while
the referrals have increased
during October 1988 due to the
absence of the medical officer.

18

18
AREAS OF

le A thorough study of the trends and pattern of tuberculosis in Tibetan
settlements in Karnataka.

2. Comparative study of the relation and impact of agriculture, dairy
farming and other socio-economic activities on health in the
different settlement in Karnataka.
3. A study of the child bearing and child rearing practices of the
Tibetan comrrunity •

4. A study of the training needs and training in areas of MCH/under fives
and school health.

5. Study of utilisation pattern and scope for integration in community
health practices of the Tibetan system of meUeine.
The above studies could be initiated by the health team themselves as
part of an ongoing Health Research strategy. Tt would enable the evolution
of a more appropriate and etiecti'/o strategy for the future of the settlers.
The studies can be of an
tion-*re^earch orientation.

1»

£
1 . The Hospital and dispensary are well equipped and organised. Most

aspects of hospital mmaagement are being looked into by the medical
officer* themselves and alternatives being explored, staff development
and continuing education programmes, however, need much mare attention.

2. The tuberculosis programme is well organised and conducted. However,
since the prevalence is very high in spite of the ccmendable efforts,
further intensification is required to bring down the prevalence to
atleast the Indian Rational average.

3. Though a •primary health care orientation* is evident In the overall
planning and training efforts, the focu* at the field level is still
very much oriented to tuberculosis. The infrastructure, health team
functions, routinee and activities geared to TB control can be, without
much difficulty and a certain creative re-oricrtstlon, fecussed on a
larger range of primary health care problems. Community based activity
need to be further strengthened.
4. The ccrcwurity participate* in decision making and pays for much of th*
health needs apart from the tuberculosis programme*. This dimension ne«ds
to be further strengthened and decentralised. Health co-operatlves/heelth
insurance schemes can be further explored.

Considerinc
cost W*
of the TB
Ally the high WWW
*** control programme, various avenues
5 * VWBAUVX
of better manegesBenb have beeo explaced in the report* The sag^eeted*1
study will also help in pointing out an appropriate course of action.
- j

n-^.' ■■■- ■

C. Health e ucatlon and appropriate Public Health Engineering will help
further to prevent many of the minor illnes ea and promote primary
health care.
7. Good cultural traditional practice* in maternal and child health need to
to he studied and fostered in the MCR prograswes.

...ao

20

8. The health workers need to be supported in carrying out at the
field level a wider range of health action other than tuberculosis
control activities.
9. The phenomena of a large mobile population predominantly of •sweater
sellers' seen to be a major problem at health practice level. A detailed
study of the phenomena and its epidemiological implications is an urgent
first step. From this, appropriate wedical/administrative actions to
tackle the problems could emerge.

10. Integration of Tibetan Medicine at ell levels of the health service
will prevent duplication of efforts and promote a more holistic
planning. Compartmentalization needs to be avoided.
11. 'Education for Health* is an area not adequately explored in the
existing health planning. The school as a focus of health activity
and health education ne ds to be explored more dynamically. Pre-scho 1
and non—formal education efforts which Include the health dimension
need to be organised.

12. Comtnunlty involvement in he 1th can be 'nrther str nrthened by
exploring tlie involvement of ycuth/youth clubs, vonen/uotnen's clubs
and the lamas in primary health care activities particularly preventive
and protnotive activities.

Ll^
K GopjLn^than

1 Prasad Tekur

on 88

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Community Statistics
1985

1986

1987

1988
(till Nov)

Crude Birth Rate
(1981 - Indian - 33.2)

16.21

12.0

11.33

6.41

Crude Death Rate
(1981 - Indian - 12.5)

8.62

9.78

8.14

4.34

Under-5 Population

741

764

696

717

- as % of total population
(Indian - 15%)

(8,52)

(8.59)

(7.66)

(7.42)

0-1 populatiirtJ

141

107

103

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Hospital

1985

1986

1987

1988
(till Nov)

Total Outpatients

25,960

21,862

21,536

14,418

Total Inpatients

612

696

625

484

Referrals

11

8

4

19

Average Stay in Hospital
(Days)

9

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Mother and Child Health

1985

1986

1987

1988
(till Nov)

Ante-natal Clinic
attendance

1059

895

864

308

Hospital Delivery

36

39

24

30

Home Delivery

63

39

33

31

Outside Delivery

45

25

28

6

Position: 2658 (2 views)