RF_IH_16_SUDHA.pdf
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RF_IH_16_SUDHA
SPAN
ectober 1974 pp!15
HSDSX
kelp fcr the family doctor BI urtsila devgon
A UHIQU3 PROGRAM DRAWS ON THS SKILLS OF
SX-K3DIC.-.L CORPSMEN Al© TEAMS TH hl WITH
THOSE OF GENERAL PRACTITIONERS TO PR0VTD3
COMMUNITY HEALTH CARR IN MANY PARTS OF
RURAL AMERICA.
IF it weren’t for Medex - a new program representing a significant break
with traditional methods of providing health care services - the small town
of Davenport in the Pacific Coast State of Washington would probably have
lest its last doctor.
Located in a prosperous wheat farming area, Davenport (population
1,365) once boasted three physicians to serve the town and its surrounding
area. Then one of the doctors left; soon another decided to do the same. As
a result, Dr. Marshall Thompson faced the prospect of handling alone a
practice he estimates was close to 3,000 patients. "The task was monumental,"
he recalls. "If I didn’t get help, I palanned to leave." As it was, he had
little time to spend with his wife and five children or to keep up with
new developments in the field of medicine - and almost none for relaxation
or recreation. H^s plight was a familiar one to rural doctors throughout the
United States: There just aren’t enough doctors to go aroimd.
Yet today Dr. Thompson is still in Davenport. His practice is thriving,
his patients happy. The answer is Medex (from the French medicin extension
or extension of the physician). "MEDEX," says Dr. Thompson, "has been a
lifesaver for me".
What Medex accomplished was to give him an extra pair of hands—and
highly qualified ones at that. They belong to Ron Graves, 29, an ex-U.S.
Navy hospital corpsman who had six years of medical experience during his
service career. Ron is one of some 30,000 medically trained personnel
discharged annually from the American armed services. About 6,000 of them
have provided what is called primary medical cai’e and have often served as
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the only medical aan abroad a ship or at an isolated station. Highly skilled,
they have had froa three to 20 year’s of valuable experience and may have
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received upto 2,000 hours of formal medical training in such fields as
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medicine, surgery, pharmacology or orthopedics. Yet when they returned to
civilian life they were' rarely able to use thia specialized knowledge. Until
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g
recently, the only Civilian medical job open to them, says the president of
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the American Medical Association, has been that of hospital orderly.
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This paradox in American medicine—a shortage of family doctors
on the one hand aid an untapped pool of highly skilled medical corpsmen on
the other - is what gave birth to Medex, the brainchild of Dr.Richard A.
Smith, an innovative young black physician who is associate professor of health
services at the University of Washington in Seattle and director of the
Medex program. Medex draws on the skills of the ex-medical corpsman, teaming
him with a general practitioner and making him what Smith calls "the first
totally new healtl professional in family medicine in this century".
Smith, who holds both doctor of medicine and master of public health
degrees, was senior Peace Corpos physician in Nigeria and served later in
Peace Corps headquarters in Washington, D.C., and in the office of the
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H.S. Surgevn General. When he went to Washington State in 1968 he learned there was
hot ealy & severe manpower shortage in the medical profession but a constantly
declining physician-patient ratio in rural areas. In addition, ths age of
general practitioners in rural areas was steadily increasing. Sonething had to be
done, Smith felt, to increase the capacit
of doctors alraady in rural areas
and also to make small town general practice more attractive to new physicians.
In the Seattle area, he noted, there was one doctor for about 500 patients; in some
rural areas the ratio was one doctor to 5,000 patients! We found doctors who were
working 14 to 16 hours a day, he said. Some hadn’t had a vacation in seven years.
Enlisting the cooperation of a group of general practitioners who volunteered
to participate in the program, Medex was launched in mid-1969 as a demonstration
project sponsored by the Washington State Medical Association
and the School of
Medicine ®f the University of Washington. Funding was provided by the Federal
Government. Interested medic-.1 corpsmen were contacted at military installations
and, after careful screening, 15 were selected to begin a three month intensive
training program at the university. This academic phase emphasized areas like
pediatrics and geriatrics, in which the corpsmen had had the least experience,
and stressed the psychological, adaptation from military to civilian medicine.
Meanwhile the Medex met the participating physicians and,with their
families, visited their, in the communities where they practiced. The physicians agreed
to train the Medex in their offices during a 12 month preeeptorship of following
the academic training and then to hire them if the team arrangement worked out.
Great care was taken in matching Medex and preceptor for, as Dr. Smith noted, "the
Medex is an extensio?. of the physician, not a substitute." It was essential
that the two work well together.
Medex (the term applies both to the program and to the new professionals)
take patients’ histories, do delegated
parts of physical examinations, stuture
minor lacerations, apply and remove casts and assist physicians in surgery, all
under the supervision and responsibility of their physicians. Statistics from
eight doctors indicate they handled 25,000 more patient visits in the first
year
as the result of their Medex. One rural physician saw 65 per cent
more patients during his first year with a Medex than he had the previous year
when he was alone.
So successful has the project been that it is continuing in the State of
Washington - and several other states have started similar Medex programs.
Medex is an excellent program, says Dr. Thomspson. If provides relief
for a lot of overworked physicians. 1^ is a plan that works, It established a
goal and got the job done.
Fr Dr. Thompson, Ron Graves provides a much needed addition to the
health care team. Graves screens patients, takes histories, conducts physical
examinations. "He knows when something is wrong, says Thompson, even though he may
noi know exactly what it is - and this is important.
The two men share night and week end duty. Thompson estimates that
each typically works a 65 hour week. People have a great deal of confidence
in Hon’s judgment, Thompson says, and I have a great deal of confidence in his
judgment. Patients know that if <bhe feels more advanced care is needed, be willcall
®e. He never ceases to amaze me. Sometimes the practice of medicine is intuitive.
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Ke’s beginning to develop this sense. It’s part of the art. They can’t teach
it to you in Medical school. Sone of the art of medicine, I think is lost
in our technological society. You’are treating people - not diseases but
people with diseases, Hon gets on very well with people? I haze yet to meet
anyone who did’t like him.
Ron ana Linda Gyaves, both from small to'.-.ns in Iowa, feel at home
in Ravenport. The;- are active in their church, have bought a house and look
forward' to raising their three snail children in Davenport. People have gone
out their way being friendly to us, says Linda.
Medex offered Ron the career he wanted but hardly Hared hope for. Ia
fact, he almost did’t aply when he first heard about the project because
it just sounded too good to be true. Now, he admits, I could
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be any happier.
He likes the wide range of experiences Medex offers and the opportunity for
further training. He has alrady taken courses in cardiology, electrocardiogram
interpretation, pharmcology and drug interaction. He sees over JOO patients
a month, scheduler, appointaents at the clinic every half hour (Dr. Thompson’s
are every 15 minutes). 1^ takes me more time to evaluate a case, he says,
and then I like to let people talk. Ip you listen long enough they tell you
what they really came for. It isn’t always what they said at first.
Ron has the knack of putting people at ease. He is especially good
with the young and the old. "Being lonely is probably the worst disease older
people have," he observes. "They want to talk. I have the tine to listen. They
need to know someone cares. He visits the local nursing home about four
times a week, making a point of spending time with each patient.
The people who go to the Davenport Clinic are delighted with Medex.
"It’s a wonderful program," says Connie Walker, Mother of three, who travels
45 miles to the clinic. Graves has taken care of her baby since the child
was two months old. He is very careful, very thorough and efficient, Mrs. Walker
says. "He explains things so
1 that you know exactly what to to when
you’re at home. He just deesn
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aces."
Another Graves enthusiast is Debra Portch who lives 40 miles away.
"My little girls just love him," she says. "He’s really got a way with kids.
We wouldn’t travel 40 miles for nothing, would we?
A medical assistant at the clinic addss He is certainly an asset
not only to the clinic but to the town. He .and Dr.Thompson have a fabulous
relationship.
What do the professionals think of Medex? Dr. Walter Borneaeier,
former president of the American Medical Association, raises a question that
occurs to many. "Are these aten competent?" he asks. "Well, one of them found
a hairline fracture in a patient which both the doctor and a hospital radiologist
aad missed. That is one example of competence".
Medex founder Dr. Smith, who has traveled widely in Africa, the Near
East, Asia, Latin America and Europe, believes the basic elements of the
Medex program provide a technological tool that can be used to train individuals
with or without previous medic.1 experience. That is part of our objective,
he says, to adapt the concept’s techniije of training and deployment of health
personnel to the existing needs and available resources in any geographic
ar
I do not think I would be exaggerating if I said this approach can be
applied in most of the 45 countries that I here visited or worked in.".
THE CHIMALTENANGO DEVELOPMENT PROJECT, GUATEMALA
Carroll Behrhorst, ND
_The following account of this;7protect. was given by its
director, °r. Behrhorst, at the last annual meeting of the
Christian Medical Commission in July 1^3. Its most innovative
features are of special interest, namelv, that health.care
should be made available to people on their terms; that the
provision of basic health care.requires a multifaceted approach
to development; and that it also requires a liberal exnerimentation in manpower training of those selected for this purpose
by the communities to be served. The'project seriously
challenges many of the presuppositions on which health care
systems are designed - and it works very successfully! .
Guatemala is a Central American country which shares one
unique feature with Bolivia and Peru! the majority of the
population is Indian. In Guatemala they represent two thirds
of the population, and their life style, habits and value system
are still very much as they were before the Europeans came'.
They have held on to their culture very tenaciously and very
successfully.. This has to be clearly understood when you are
working with them. In fact, it makes your work easier because
you are dealing with people who do not try to be like you or to
copy your ways. lou are obligated to work with them on their
terms.
Guatemala is a very poof country economically. Its gross
national product is the lowest in Latin America.. Only 2 percent
of the children finish the sixth grade of school. Where we
live, in Chimaltenangowhich is the capital of a politicaldepartment and-only 50 km from Guatemala City,' only 10 percent
of the children attend school. This is because the Indian.is
mostly interested in practical things which he considers useful.
j-o’him it ±s most important thatjhe be a useful and loving
human being, and, therefore it is hard for. him to accept
theories. EOr this reason he has little time for formal
education, because he does not consider it very useful and,
moreover, it
* is a part of the European culture which he is not
prepared to accept.
These people have serious health problems. Malnutrition
is very high, and 90-85 percent of the children are at least
moderately malnourished. The death rate is also high,”
especially among the Indian population in the highlands of
Guatemala. Approximately 50 percent of the children die before
they are five years old. Another problem related to health
is that of land tenure. It is estimated that 2 percent of the
population own approximately 90 percent of the tillable land.
Therefore, you cannot avoid this problem when dealing with the
health and development of the Indian people. However, it is
an extremely difficult problem to deal with, because those
who own the tillable land are most reluctant to see the Indian
have ownership. Bq, one has to move slowly.in developing a
model of land resettlement, but we have started, even though
there is little to show for our efforts thus far.
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Let me tell you how I became involved, in this work. After
finishing my medical education in MiSSOuri, I was anxious to find
a field of service outside the USA. One day I?read an appeal in
the Lutheran Witness, which is a publication of the Lutheran
Church - Missouri Synod. It called for a doctor to serve in
Guatemala.
I telephoned the director of the Latin American
section of the'mission, arid he told me that they were anxious
to reopen a hospital which was located in the ancient capital,
Antigua. . After several visits' to the country,- I decided to
settle there, but I was doubtful whether Antigua offered an
opportunity for meaningful service. I suggested to the mission
that we." move 20 km from Antigua to the town of. Chimaltenango,
which is the capital of a: large department, with about 2'00,000
population,: and where the only medical facility consisted of a
small clinic handling"15 patients three_times a week. The place
vras bereft of services, whether for health, agricultural
extension, or any other kind of social service. Having made
the choice to work here, it became difficult to continue,with
the local mission, which seemed more interested in promoting its
own organization than in service to others. Nevertheless^ I
must admit that, though I may be critical of Christian missions
and their organizations, it is they who pioneered in this field
of service for others,-and without their inheritance I would
never have been mov.ed to~work in Guatemala; and with.O”t the
help of Christian workers! would never have been able to
develop our programme. I owe a great deal to Ivan Illich who
has a very healthy and basic understanding of what peopl.e and
communities need. His recent book, 1 Rebuilding Society , provides
an excellent diagnosis, although I am less sure about, the therapy.
Two others who have helped me in the development of programme
are Dr Wolfgang.Bulle, the medical director of the Lutheran Church
Missouri Synod, and the Reverend Ralph Winter of the United
Presbyterian Mission, who is now teaching at the Fuller Seminary
in California. I must also point out that when I talk about the
programme in Chimaltenango, I am referring to the whole team of
55 workers. Some work in the hospital' and clinics; other work
in the medical and agricultural extension and family planning
programmes.. We .work as a team, with each entering into the
decision-making process. The doctor helps with the cleaning.
The cleaners assist with injections.
In Chimaltenango we felt that we must begin by knowing the
people - what they were like and what they thought they heeded.
This is easily said, but not so easily done. The more usual
pattern is to start by recognizing that they have no medical
services and putting up a building immediately, with a big sign
outside "Open for service". However, we had to discipline
ourselves in order'to think with.the people on their terms,' so
as to see what their needs really were and"what they thought
they needed. Most of us, in this kind of situation, see that"
children are dying of diarrhoea, measles, and so on. There is
a high incidence,of. tuberculosis. We want to.start treating
these people bygiving immunizations, for’this is what the
average doctor is trained to do; and it is also very gratifying „
to do the things you think are needed. The only difficulty is
that you are then helping people on your terms, and not on theirs.
let if you are really going to help people and be.concerned about
them and love them, you must love them on their terms, not yours.
This is very difficulty for a technocrat who comes out; of a US
medical school, because he has become accustomed to think in
terms of what he can do FOR people and not what he can do WITH
them. After all, we have the technological tools; so we decide
that we will lower the infant mortality rate and lower the
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measles rate, and that people will have fewer children - but
always on our terms. It rarely occurs to most of us to sit down
with people and simply ask, "What do you think you needYou might be surprised by what other people think they need.
We think they need triple vaccine and more protein in their
diet, and while it is true that they need these things, they
are probably much more interested in other things altogether.
About three months ago, we visited a village high up on a
mountain. We did have a programme for the women of the village
at one time, but for various reasons it failed. _There were no
services of any kind available in this village, and we decided
that we would try again to reactivate the women's club. After
calling the women together,, we told them that we would like to
work with them again, but that nothing would be”done until they
had. had an opportunity”of discussing their needs with their
husbands and neighbours. We knew that most of the children in
this village suffered from diarrhoea, but, we did not want to
start' with a medical programme until we had first listened to
the people's own expression of their needs. A month later we
returned and spoke with the women again. They did not say that
they wanted medicine for diarrhoea. Instead, they saids
Api
our chickens died.' That was really a problem for them because
rney were
kilometres from the nearest market which only
opened once a week, and so meat was no longer available to them.
Normally,- chicken is their only source of meat. They also
complained that there were no eggs, for their children, and that
the new eggs were good for them. They then went on to say that
another need was to grow apples. They grew well.at that altitude
and could be sold profitably in the market. These then were the
things they needed - chickens and apples. Nothing else was
discussed, and we promised to send them an agricultural extension
worker who would teach them to build proper checken houses and
how to feed and immunize the’chickens. And when the right time
of the year comes around, he. will help them plant’apple trees ~
nothing else. When you help people on their terms, you have’no
acceptance problem. lou may think'I have overemphasized this.
point, but I think it is very necessary. Even though community
health programmes may look very good on paper, they often fail
because they_have been designed.solely by professionals and”have
not' started by helping people oh their own terms. Religious
organizations are often the worst offenders in this respect.
When we first began in ^himaltenango, I did nothing but
walk around the town and get acquainted with the people and play”with the.children. Gradually 1 would be invited into their homes
to have coffee with them or to sit down to a meal of’tortillas
and beans,. This went on for three months until I was weJl-^nown
in that, tovna and accepted. Then we rented a building for ^25
a month, so there was ho investment. One hundred and twentyfive
patients came that first day, and.we have never had'1 ess than.
that number since. They now average 200 per day. Giving curative
services is no problem. It is easy to’cure someone, but not so
easy to keep him well. The orientation of our programme is not
to think in terms of medicines or in terms of disease, but rather
to think in terms of health and life, and vital life, or what
Ivan Illich calls convivial living. Curing is not the important
thing. It is much more important to encourage life5 and this”is
not very difficult in Guatemala because the Indians themselves
are dedicated to life. They are a very biophillic race. They do
not think in terms of death, because death is considered to be a
perfectly natural thing. After some experience working with these
people, we came to realiz'e that they were in need of other
services besides health care.
...
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The following list represents our present estimate of priorities
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- social injustice
- land tenure
- population control
- agricultural production and marketing
- malnutrition
- health training
- curative medicine.
You notice that I put curative medicine at the bottom,
which is where we regard it in our list of priorities.
We soon realized that all the things I have listed above
are part of a total community problem. Moreover, they are all
interrelated. For instance, the incidence of tuberculosis is
related to land tenure. In San <fuan Comalapa, each Indian
family owns a small tract of land, Md so they can produce
vegetables and corn. In fact, they often have more than they
need for their tortillas, so that they can buy some meat
occasionally and some eggs. They not only eat better, but they
tend to be less crowded. Wow, it is known that tuberculosis is
a disease of poverty, primarily because of poor diet and crowded
living conditions. On the other hand, in an area around
San Martin, the land is owed by wealthy landowners, who are
always white, and it is in this area that the incidence of
tuberculosis is very high. Therapists tend to think of treating
tuberculosis with drugs,_although they will concede that_the
the best way to treat tuberculosis is to improve the diet." But
this method of therapy is not the way to treat tuberculosis in
the Department of Uhimaltenango. Such treatment would have a
negative effect if you"simply treated-the people who_are
clinically sick, because then you would divert too much of your
energy to this technological gimmick, whereas the basic problem
lies in the maldistribution of land. Until you work with that
basic problem, you are probably wasting your time. You may
think you are doing something effectively, but you are not.
This illustrates how,you get into all kinds of activities, once
you become involved in total community service. This is the
reason why a doctor li^e myself has to become involved- in a land
development programme in order to ma’-e land available to farmers
through our land loan programme. Some of our Indian population
had to break up their families in order to go down to the south
coast to work on coffee plantations. They would be away for
three or four months at a time and be exposed to diseases they
had never been exposed to before and would come back half sick
and spend all the money that they had made in trying to gr t
well again. The only way we could help them was to give them
loans in order to buy a small piece of land for themselves.
In one project we have made money available to 56 families who
now own their own land, consisting_of five-acre tracts. Ml of
them have increased their corn production at least four times,
and one even increased it ten times through good land management.
Mt er the first year, most of them were able to pay back as much
as a third of their loan. The money is loaned over a five-year
period at 8 percent annual interest. Repayment"!s no problem.
The problem is to find the capital to make loans available, and
we are always searching for more money to add to the loan fund
for land development.
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I have mentioned that Indians are a very biophilic race.
They do not take kindly to limiting their families, ^et, if
they continue to have an average of six to eight children, the
next generation is going to be in serious trouble again, in
spite of the fact that they now own some land. For this reason
we have a family planning programme, but it requires patient
education for people to see the consequences of overly large
families.
We have a programme for the training of health promoters.
It is not difficult to train to train people to apply and to
accept a Western style, of health services, The Indians are
ready to accept anything which has proved itself useful and
successful. They are willing to accept that a little boy with
high fever and a lotof cough gets more benefit from an
injection of penicillin than from drinking some kind of tea orputting leaves onhis chest. In fact, they use very.few
so-called traditional drugs. Before we came, the Indians would
purchase their.Western medicines from the pharmacists,"and
every little tox-rn had someone who would give, injections...
These pharmacists were primarily indigenous. They had no idea
what the patient was suffering from;„they lust sold him some.,
medicine. The situation has now changed somewhat., because the
Government is training health workers who visit local clinics
twice-a week. 3ut ten years ago nothing li^e this existecl,
and so we had to develop a training svstem.so that Indians could
be taught :how to.recognize common medical problems and how to
treat them - not to be para-medical workers but actually be
curers themselves and. really be responsible, for offering total
community health services.
We have found that it is very important to be careful in
the selection of those who are to be trained. Originally we
took those who were recommended to us by a local priest or a
Peace Corps volunteer. We have since learned that this is not
the ideal way to select people. 0ur approach now is to assist
each local community to set up a community betterment committee
which includes a health committee. The the community health
committee selects someone within that community whom we_are to
train. This has worked very well because it avoids some of the
pitfalls that we have in.the medical monopoly in_the Western
world. The man that we train represents the communityj and the
community then is responsible for him and can discipline him.
We had to withdraw one of these" health promoters because the_ .
local community health committee was not~hapfy with the way in
which he was offering his services.'"This local committee has
a list of the prices of' the medicines. Each man is allowed"to
charge according to this price list., and the community knows.
what the medicine costs. In’addition, he can charge a 25-ceht
fee for his call or for his services. Since the’community is
involved in setting the charges, it becomes impossible to
develop_a monopoly like we have in the Unit.ed States and many
other places in the world, where the doctor’can charge any fee..
he likes. .Where doctors hold a monopoly, as they do in most
countries,"they are then able to set the fee and the conditions
for their services. We wanted to get the service out of the
hands of this monopoly, and so we insisted that the community
which wants a community health leader must first form a committee
which will be responsible for him, both during his training
and later.
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The training is very practical. They spend a good deal of
time" making rounds in the hospital and seeing^actual clinical
cases. They learn to know what they can do in their own village
for a particular'problem when they are responsible for it.
Treatment is by symptom only. They"are not taught to interpret
symptoms.. Tn ray experience,"this is very important. When I
liras in Africa recently, I visited a hospital where an American
doctor was training medical assistants, and he told me tHat
when he checked their reliability, lie, found that~they mistreated
45 percent of the patients._ That is very serious indeed. These
medical assistants had received_verv sophisticated training,
but they were getting into serious trouble_becau.se they were"
trying to interpret the svmptoms in order to make a diagnosis.
It is in interpreting symptoms that doctors make too many errors.
A lot of them would get in less trouble if they wo^ld simply
listen to the patient and then treated what he told them, instead
of relying on complicated gadgets. I think it is very important
to understand that in order to treat people, you have to spend
time listening to them. It is a big defect in modern medicine
that doctors do not- take sufficient time to listen. The average
patient will tell you what is wrong with him. For this reason
we teach our health promoters to treat symptoms, and their
reliability is quite high. In a study which was made about five
years ago, 91 percent of the patients were treated properly-. If
a well-trained doctor treats 91 percent of his patients properly,
then he has an excellent-record 1
We are now developing a two-year study of the reliability
and acceptability of our health promoters. We also want to know
whether their position is affecting their status in the local
community. You will be surprised to hear that some of those
we have trained have never gone to school'. However, it is not
necessary to go to school, to be able,to practise medicine. The
complicated training which the^doctor receives is perpetuated by
the medical monopolists in order to continue"their monopoly.
One.of the necessary components in the success of our programme
lies in the careful supervision of each health promoter. This
again is rather different from normal medical practice. The
only supervision an average doctor receives is when.he gets too
far.out of line and a lawsuit is brought against him. If he does
something very bad indeed,- he might be discharged from the
medical society;’ but that is a rare thing to happen because
doctors are not Very good at disciplining each other.
°ur hea ;h promoters are supervised in various ways.,
ofi§ho?n?h^g ;q come for at least three davg every month/ On
ys they will have to under take a written
examination in which they are given patients to see, and
then they have to describe what they would do for this particular
problem at home and what they would recommend to the family
so that the problem need not recur. If they ma^e a failing
grade in the examination, they are not allowed- to buy medicines
for a month until they have passed the next examination. Some
people would say that if'they do not have medicines, other
people in the village will suffer. That may bo true, but we"
believe that it is more- important that these health promoters
act in a responsible way and -are capable. If they are not
capable? they should not be allowed to work.
Ue have also used a visiting supervisor.' Unt.il_three
months ago, we had a British doctor doing this. He would visit
each one of the health promoters’"and spend three days a week with
him, also visiting the neighbours and looking into the quality
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of the promoter's work. HG would note if the house of the
promoter was clean and if he had adequate medicines and observe
his methods for cleaning syringes, etc. WG now have one of our
own health promoters who has taken the place -of the British
doctor 'as a visiting supervisor, even though he had only gone
through the. second grade. ~He is already doing a’remarkable lob even.better than the British doctor who went to school for 22
years. This is no., ref lection on the doctor but is because of
the^nature. of .the local supervisor, who is an Indian himself and
can understand his feiqows arid discipline them more effectively.
This again supports my contention that we must break do^n the
medical monopoly if we are going to bring health care effectively
to people who now have no service of any kind. When most people
think of health, they think of the doctor; but the doctor actually
has very little to do with health, even though he takes credit
for it. Nature cures most problems. Seventy-five to 30 percent
of most illnesses are self-limiting. The patient roes to the
doctor who gives him an injection or some drugs", and after about
a week or ten days, nature takes care of him itself. The_doctor
takes credit for nature’s work and is paid for it, and yet
sometimes the doctor has had a negative effect because his drugs
have delayed the patient's normal, natural recovery. It will not
be easy to break this medical monopoly, but perhaps in the next
generation people will realize that they do not have to go to
the doctor for their health. People have to be taughi to take
care of themselves and to know what to~do when these self-limiting
illnesses occur. We still need doctors to diagnose and treat
some of the more complicated conditions.
Finally, let me summarize the salient features of our
community.programme in Chimaltenango. Some of the principles
enunciated here may be of help to others who wish to start such
programmes5
- The concept of complete orientation to those to be served.
This is the first essential step.
- If you do a demographic survey, be sure it includes the
guestions, **
What do you think vour needs are?" and
How do"you thin1-- we.can help^you?" Avoid offering
services on your terms..
- Community health committees of local people should
first be organized and functioning before first aspirin
is given out or a band-aid put on. These grass-root
committees in each community then themselves select the
people to be trained to offer the services, supervise
them, discipline them, report on them, and are in
complete charge. The community committee will set the
standards of services and the prices charged for it.
- Community services are just that p total service for the
whole community, including all types of services
required, depending on local needs and custom and
availability of materials. The practice of medicine is
only a small part of the total pattern, which includes
responding a total community needs, whether that be
in the field of agriculture, marketing, housing,
homelcrafts, nutrition,' family planning, schooling,
transport, etc. The hospital compound will not be
... 3/-
- ..8
-
possible in’such a scheme, and the compound walls
that do exist will be battered down so that all services
and work and love freely flow in all directions.
- Outside input is obviously needed in materials,
manpower, head-power, direction and_ supervision - but
always in terms of local custom and tradition, along
with a complete dedication by the expatriate to
training his local counterparts.
- Community health promoters (or medical assistants, or
dressers, dr whatever label they might bear) should
always be selected by the community to be served.
- Training should be arranged.so that the trainee can
continue his usual work, continue his family and
community identity, with absence from his home?at a
minimum. Training programme at distant centres too
often disrupt family and community identity and may
corrupt the trainee with exposure.to a "foreign,,culture
and life style which make return.to his family.and
community difficult, if not impossible. If absence
from h°nie is necessary, the courses should be short,
with frequent return to.family and community.
- Medical training demands use of clinical patient
teaching material in either a dispensary or hospital
type service, so that the clinical picture is seen and
appreciated and understood.
- Treatment of ailments is.done by symptoms, not by
diagnosis. Even people with the most sophisticated
training, with years in school to understand the
mechanism of disease, too often err in their
interpretation of the symptoms to make the diagnosis.
Our experience is that symptom treatment results in a
relatively low error in management, realizing that
most medical problems are rather simple and, with
nature's help, actually heal themselves.
- Medical training demands"that the trainee know equally
well what not to.treat as well as what to treat and
how to treat it. The future of nonprofessional curing
demands that this concept not be violated.
- Supervision of lay curers is obligatory, and the nature
of this supervision depends on local circumstances. .In
the Guatemala programme this supervision is done by
requiring regular attendance at’ clinical training sessions
regular examinations (both oral and xjritten), regular
visits bv the supervisor to the health promoter's site,
and regular reports from the local.community health
committee about the health promoter's work, its
quality and acceptance and the fees charged.
- Fee-for-service should be decided locally, but the
central agency should not, under any circumstance,
put anyone on the payroll. The community’ is being
served, so the community pays - with-no exceptions.
If this work is undertaken by a-mission or a church,
the only people to be on the payroll should be trainers
and supervisors - nobody else.
... V-
9
- Medical curative services should pay for themselves^
without exception. Dependence on outside input adds
nothing to.the development of local responsibility and
supply of services and materials.
*
*
*
CMC NEWS IN BRIEF
(EPS) - For the remaining two years of its current mandate,
the Christian Medical Commission (CMC) will concentrate on the
development of basic health service's for deprived peoples.
This decision was made by the Commission's six-member Executive
Committee, which met in Tubingen West Germany) on January 11
and 12, under the chairmanship of Dr John H Bruant, director of
Columbia University’s School of Public Health, New York.
’’For the past five-years we have been trying to persuade
the Christian churches~to look at the needs of"the 90% of people
in developing countries who still have no_access to health
care", said CMC'g director, Mr. James McGJlvray., at the close
of the meeting. "But"most of the churches~remain committed to
the maintenance of hospital services. These hospitals, in turn,
are trying to follow the high standards of medical excellence
taught in the Nest, even though they realize that millions of
poverty-stricken people cannot provide the support base for a
Western-style hospital system."
Now the CMC is acting to implement a mandate drawn up last
July which said a lust system of health care delivery must work
out new ways of providing a basic minimum of services for all.
Specifically, this will mean focussing on national agencies
doing joint planning and coordination of all existing resources
in health care, whether Protestant, Homan Catholic or governmental.
These already exist in several countries.
In the past six months the CMC has helped to activate additional
agencies in Botswana, Lesotho and Nigeria, And Kenya seems likely
to follow in the next few weeks, according to Mr. McGuvray.
CMC will work closely with these groups/to develop-projects
providing such basic services as immunization, maternal and
child care and advice on family planning, safe drinking water and
waste disposal, health and nutrition education, diagnosis and
treatment of simple common diseases and facilities for referral
of acute ailments.
An essential condition-is that the services be available whore
people live. .Towards this end, the CMC is promoting the idea of
training such people as school teachers, Bible women and
evangelists,_so they can aid in basic health-programmes. It is
essential to' give enough training', but not so much that the
person leaves the area where the service is needed.
„The Executive Committee's decision to concentrate on worje
with national planning agencies does-not prevent the CMC from
responding to any opportunity to promote the same principles
elsewhere, as it has already done in’_Koje Do (South Korea) and
Jamkhed (India). But a situation must offer promise of more
than local impact, the CMC director stated.
1k'
THE SCOPE OF HEALTH PROTECTS
- Ey Imrana Qadeer
( Background paper for the 4th Annual Meeting of MFC)
The present decade in our country can be described as
a decade of widespread disillusionment among doctors who uptil^
now have been used to considering their profession a panacia
for all human sickness. This disillusionment is a result of
the very obvious reality of excess of death and disease in
the society inspite of all the technological advances made
in the field of medicine and all the efforts put in education
and training of doctors. Our proclaimed ’progress’ and
'developmemnt’ in the fiold of health fails to stand up to any
objective scrutiny of its achievements.
This disillusionment has compelled a number of young
doctors into actions of various kindsfwe shall here not tamper •
with the breedings of the cynics who are themselves a product
of this same disillusionment). The nature and the direction
of such action obviously Varies with an individuals own
understanding of the nature of health problem, the nature of
health problems, the nature of technology, the forces which
govern the growth of technology and its application for the
benefit of the masses and the nature and dynamice of society
itself.
This difference gives rise to the possibility of these
action programmes working at cross purposes or becoming less
effective due to the limitations of their own understanding.
The important thing therefore for those involved, is not to
get confined to their own experience., but to make it a part of
a wider effjfrt at collective learning, Inspite of wide
variations in the details of their health activities -at
various levels and of different kinds- the workers can
easily recognise certain common issues. Even negative find
ings and methodological errors, if recognised?become tools
for improving ones’ comprehension of disease in society and
hence future action. Exchange of ideas and experiences there
fore is an essential component of the effort in lessening
the subjectivity of our thoughts and action.
It was with this objective in mind that we decided to take
up an analysis of some of our own projects this year. Un
fortunately out of the eight expected reports only three have
come and therefore the methodology of this background paper
has to be slightly different fromihat was agreed upon. Inter
estingly enough the three reports which we have received
have entirely different approaches to the problem of community
health. It is not intended to compare and contrast these
:
projects, 'however, certain issue's are raised on the bads of
<
the material provided regarding project work and the lessions
'
which we can’d raw from them. The reports from Midnapur, Thaltej
and Dharnampur together with others will form the basis for
discussion pn the issues raised in this paper.
contd. ..2/.
contd....2/Pro.ject work as a learning experience:
I. What doos it teach us about
i) Occupation(Productive activities) and working
conditions of the people.
ii) Their social and cultural background.
iii
) Economic status.
iv ) Living conditions- Housing,water supply,sewage,
drainage,food,clothing,education and transport.
v ) Class distinctions and stratific-ations within the
community and the dyanamicity of social relations.
vi) Nature of exploitation in the community.
vii) Welfare activities int he community.
viii) Political forces.
II.
How do we relate the above factors to health issue st
Nature of health problems and the above factors: For
example how do we relate the incidence and prevalen-ce^
of diarrhoeas,intestinal parasites,respiratory infec- W
tions(including T.B.) Malaria,anaemia,under-nutrition
and scabies in Midnapur,Dharampur- and Thaltej with
the prevailing ecological set up?
ii)
Health Behaviour of people and its relationship with
the above factors:
There are two ways of looking at this probleL accord
ing to one,human behaviour regarding health problems
is determined by inherent characteristics of man and
can be assessed as medically correct "or incorrect
independently of the surrounding social,biological
and physical environment. According to the other view
point,health behaviour of people is determined by
their experience of traditional and modern means of
health care within the limits of their environment.
Hence, all health behaviour must be analysed within
the socio-cultural and economic frame of the community
rather than within the paradigmes of medically corre-c w
or incorrect.
i)
Given the experience of the three projects which _____
of these two ways appear logical to us? It may be easier
to come to a conclusion if we try to explore the follow
ing quo stinns:
a) What is the reason for the tenacity with which
birth practices and supermacy of the grand mother's
in MidnapUTr, is maintained?
b) What is the reason of poor hygiene and irregularity
in treatment of chronic illness(and even acute
ones) among the tribals of Bharampur?
c) Why are they lazy and lack initiative?
d) Why even after 10 years of services their health
behaviour has changed so little?
e) Why in Midnapur health education is being taken up
indirectly through nightsoil disposal programme?
contd...3/-
contd*....3/£) Why in all these areas inspite of high infants
mortality people continue 'of depend upon tradtional
dais and their services.
ill) The limits which the above factors impose upon
health cares
These limits are a result of the difference between
the socio-cultural and economic status of the proviers and the recipients of health cafe and the pooor
living conditions of the majority of recipients.
a) The CSC programme at Thaltej has an extensive
structure but its very structure due to its com
position is its limitation. Similarly,the extreme
poverty in Dharampur and-Midnapur is a barrier
between people and project workers.
b)
Poor living’ condition limit the impact of medical
care for example the effectiveness of treatment
of diarrhoeas in malnutrition and of malnutrition
■ in a child with chronic diarrhoea or of both when
the child continues to live in the same environ
?
*
ment,becomes less.
Are any of these limitations effectively
demonstrated in the project areas? Here Thaltej
may be a good example sines poverty is not as
evently distributed as in the othe£» two.
Ill,
Can we then tackle health problems independently
from socio-cultural and economic problems?
IV.
Are majority of our health problems emenable to tie
available preventive techniques‘ If so, have they
been quantified. For example, of the respiratory
illness how much is prevented by DPT immunisation?
V,
What is and wnat should be the role of curative medi
cine in health care programme?
What is the real meaning of health education and
how best can it be achieved?
VI.
Is experience a part of health education or can
transmission of knowledge alone serve -the -purpose?
B, Projects as alternative for health care;
f. What are the requirements of evolving an alternative
stratey?
i)
ii)
Are we clear about our goals?
Have we assessed the quantity and quality of
■problem?
iii) Have we set the priorities according to the
felt needs of the people and epidemiological
status of the health programme?
iv) Have we assessed our resources both in terms
of man power and material?
n
v) Have we considered the choice of techology
for handling the health problems on hand?
contd....4/-
contd,...4/Have we evaluated the training needs for the
proposed project? Of the various projects,how
many can fulfill these criterias?
II.
Give the resource inputs of the projects what are the
chances of their being reproducable?
III.
What is the population coverage of these projects and
is total population coverage feasible through similar
efforts?
IV,
Can these projects be sustained, and become self-sufficient?
vi)
G.
Projects as an instrument~of social change
Given the fact that the direction of social change
can he varied, the role of these projects has to
be understood clearly.
i) A means of easy money (which' .Tn abundance through
national and international funds) and a source of
prestige.
ii) A means of social service to somewhat hssen the burd,en
of the poorC(Philanthropic).
iii) A means to reform the society where the sores are
a
healed but the disease persists. (Reformism).
iv) A means of establishing contact between doctors
j
and people so that both sides understand each
1
others limitations, needs and objectives.
.
v)
A means of reorganising ourselves. If we are inter
ested in the later three roles then which aspects
of the project work ne«5d to be strengthened,? • \
1.
Some issues regarding., running of a project
D,
Given the voluntary nature of work and the main
objective of learning about community health, some
of the following issues need to betaken note of. It
is also worth looking into projects to see how these
issues are taken care of in practice.
A personality oriented programme has the danger of
becoming dependent on one person.
A
ii) In projects run by studdnts the problem of continuity
and regularity threatens the success of the programme
or not?
iii) permanent employes either make the project personality
oriented or undermine the objective of voluntary
participation and sharing of responsibility^iv) Administration of the project in itself takes too
much time of doctors.
v.) Doctors tend to become the centre of all wisdom in
these projects.
ri) Since donation in kind and otte rwise comes from richer
sections and they have more time for and knowledge of
medical care services,they tend to get more out of
the project work than the rest of the community.
i)
contd.. .5/-
contd....5/-
vii)
Not enough attention is paid to systematic evaluation
of objectives and achievements.
viii) Interference by and interaction with government and non
government health organisations and individuals.
ix)
Training of workers and its assessment.
x)
Should the worker be outside or local? Advantages
and dis-advantages of the two.
B.
Poeple’s participation in projects.
I.
i)
ii)
iii)
iv)
v)
H.
What should be the quality of participation?
To seek help and treatment.
Donate land and money
Taking part in decision making
Taking part in implementation of programmes
Taking part in evaluation.
What factors influence the quality of participation?
dan we take example from the projects to demonstrate
the Influence of the followings
1) Social cultural and economic barriers.
ii) Technical know how.
iii) Access to health services.
iv) People's experience of effectiveness-of -servieasy'"’
v) Distances between places.
vi) Educational status.
vii) The health team itself.
Taking the above points it may be possible to see which
sections have what quality of participation and why. This
helps in unddrstanding the needs and require® nts for a
better participation.
HI.
What efforts have we made in our projects to mobilise
people.
%****
VOHEIKG- PAPER
ROLE OF FROST TINE WORKERS Iff DELIVERY OF HEALTH CARE Iff INDIA
Luis Barreto - Lecturer Community Medicine Department
M.C.I.M.S. - Sevagram
2.
The present medical manpower produced both in the developed
and in the developing countries has been inadequate and more impor
tant still incapable of delivering health care to the people who
need it and in places where it is needed the most.
3.
The world Health Assembly has in its 31st Meeting in 1976
decided that the main social target of governments and W.H.O. in the
coming decades should be "the attainment by all citizens of.the world,
by the year 2000 of a level of health that will permit them to
lead a socially and economically productive life."
4.
The Alma-Ata declaration stressed the need to provide
Primary Health Care. This was to be the key to attaining the
target of health for all by the year - 2000.
5.
The main people for delivery of primary health care would be
the Front Line Workers. It is to be noted however that neither
primary health care not front line workers are a new concept. At
best one could say it is a new jargon. But new jargon is not a
bad thing, for it- evokes renewed interest.- But it is bad, if it
does not take into consideration our past experiences. It is
based on the sharing of experiences of various countries on utili
sation of front line workers in delivery of primary health care
that this concept has come to be envisaged as one of the main
pillors of the National Health care Delivery System. One must also
note that in India projects like Jamkhed in particular and others
like Mandwa, R.A.H.A. etc. have been utilising front line workers
even before the Alma-Ata Conference.
6.
The Government of India launched the C.H.W.'s Scheme on .
October 2, 1977 in an attempt to strengthen the health services at
the grass roots, and solve the two main problems our countries’ ■$.
health services has been facing namely:
a) Outreach
b) Active community participation.
j
ANGA l C
INTRODUCTION:
1.
The Health status of hundreds of millions people in the
world is far from satisfactory and in fact unacceptable. More
than half the population does not have the benefit, of, adequate
health care. There is a wide gap between the developed and the
developing countries in the level of health and in .the resources
they are devoting to the improvement of health. Moreover within
individual countries whatever their levels of development, wide
disparities exist between health facilities and health conditions
of different groups of population.
dj
2
7. Projects in various countries like Bangladesh, Burma, Thailand,
Indonesia, Nepal, Ceylon and India and in some Latin American
countries have since long been trying to deliver primary health care
through front line workers known as either village health workers,
£ommunity_ health_wqrkers, village health communicators villa ge
health volunteers, village health promoters etc. These workers are
either part-time or full time, paid or unpaid, literate or illiterate
or both, male or female or both etc.
8. in our country the former government launched the C.H.W.'s
scheme on Oct. 2nd, 1577. This new rural health policy incidentally
is supposed to reflect the ideological concept and rural bias in
the field of health. By September, 1979, it was estimated that
180,000 C.H.W had been trained. The scheme had been extended to
981 PHCs. The scheme covers all states in India except Kerala,
T.N and Jammu and Kashmir, Karnataka agreed to the implaentation
of the scheme only since April, 1979.
It is to be noted before we proceed that in 123 blocks (out of
892 blocks in the tribal areas) ^HCs have yet to be set up.
9.
Frontline workers in_India:
The front line workers in different projects.in India are;
a) Village Health Workers in jamkhed (? Randwa.
b) The village health promoters in Raigarh (RAHA)
c) The Anganwadi workers in the 100 Integrated Child Develop
ment Services Scheme in the various tribal, rural and urban
blocks in different parts of the country.
b) link workers in the Tea and Coffee Plantation in the South.
e) The Community Health workers in different parts of the
country in our villages, etc.
10. what is the.role of the front line workers in delivery of
primary health care? Different projects have assigned different
roles varying from mainly a role of an informant and an educator,
as in the plantation, to treatment of minor ailments and collection
of data and treatment of malaria, sanitation and health education
as in the case of village health promoters, C.H.W's etc. In projects
like Jamkhed the VHW's have besides delivery of primary health care,
also been involved in total socio-economic development and in social
change in the community.
a) what according to you should be the role of these front
line workers, taking into consideration in particular the
C.'H-W.'s Scheme?
b) Should they involve in activities besides health
*
?
..../3
3
•11. Criteria and process of selection: In Jamkhed the community
is informed about the type ofworker required by the doctor, and
the social workers and ANMs, and the community select the worker.
In the plantation, the selection is made by the supervisor and the
manager of the tea garden in consultation with the medical officer
and the community.
In the Integrated Child Development service Scheme, the Block
Development Officer and Child Development Project Officer are the
main selecting authorities. In Raigrah Ambikapur Health Association
the church authorities in collaboration with their social worker
and community select the worker - The CHW's should ideally be
selected by the Gram sabha - but this seldom happens and it i-s largely
the Panchayat workers and the Medical Officers and other political
workers who eventually select their protegees.
Which system according to you is better? Why?
Do you have any suggestion as to how the workers could be
selected?
c) Considering O.H.W.'s scheme in particular -how could one
ensure that the right people get selected?d) What should the sex/caste/economic class/education of the
worker be?
12.
TRAINING: The mode of training differs from place to place.
In Jamkhed an initial training in the headquarters for a week
is followed by in service training in the field in their respective
villages and coupled with refresher session they, work for a whole
day,.where working come to the headquarter every Friday stay and eat
together (this gives them an opportunity to share their problems
and occasionally find solution from each other experiences). This
is followed by another day (Saturday) of review of the weeks' work,
collection of data and checking of records (done by M.O. and A.N.M.
Social Worker), teaching of a new lesson and solving their problems
or rather helping them to find solutions.
a)
b)
Link workers from different gardens come in batches to the head
quarters in coonoor or to their respective garden hospitals for
weekly training mainly in data collection, sanitation and are also
thought the methods of production and transmission of disease and
treatment of the same by the Medical Advisor or the Medical Officers.
In R.A.H.A. training is given by social workers and Nurse-Midwives
in one of the villages for 15 days and followed up with refresher
session for 15 days every 6 months.
The Anganwadi Workers are trained in different institutions selected
for the purpose by the Project staff. They are trained by doctors,
.../4
social workers etc. for 5 months.
training.
Some of them receive in service
The CHW's are trained hy the M.O. and M.H.W, with occasional guest
lectures at the P.H.C. and some field training.
Most of the projects utilise Audio-visual aids, but much stress
is laid in Jamkhed and plantations and R.A.H.A. and some of the PHC's.
Jamkhed utilised locally relevant audio-visual aids.
The methods of training vary from mainly didactic lectures with not
much stress on in service and field training to much stress on field
training and purposeful, problem solving meetings as in Jamkhed and
Plantations.
a)
b)
c)
d)
e)
f)
g)
Who should actually give the training?
Are the doctors in our PHC capable of imparting training to CHW's.
Should these doctors receive a training themselves?
If so, where should they be trained? For how long?
what type of training should they be given?
• Should the PHC-MO's train their MHW's to teach the CHW?
Could Medical colleges involve themselves in training of the
M.O. + M.H.W.'s.
h) What, according to you would be the best way of training the
CHW's.
i) Contents of training, skills imparted to VHW's and the level
to which they should be traa ^ed. Should the training be uniform?
j) What educational methods and principles should be utilised in
training the VHWs.
■k) Main training emphasis on professional (health work) skills
or on how to conscientise people about socio-economic problems
and actions? or Both?
13. a) Should workers be part time/full time?
b) Should they be honorary or paid?
c) If paid, how much? Cash/Kind?
d) Who should contribute the money and through whom should
the payment be done? One who does payment will effectively
control V.H.W.
14. Reactions of Community to CHWs.: In projects like Jamkhed,
R.A.H.A., Mandwa and Plantation majority of people are happy to have
somebody to give them basic health care.
However there is a large amount of dissacisfaction with the govern
ment in various parts of the country also in some of the projects.
Some of the reasons are:
i) Not a dedicated worker
ii) Not enough knowledge
iii)
Does not give injection
iv) Not accepted by the community
v)
Helps only the rich and affulent.
What according to you are the main reasons for this?
.../5
15.
a)
b)
c)
What should be the sex/age of the worker?
Could religion/educational status/sex/age affect performance?
Should socio-economic conditions be a criteria for selection?
16. Evaluation: What should be the methods of evaulation of perfor
mance of front line workers?
a) Decrease in morbidity and mortality in the community/vulnerable
groups.
b) Immunisation status of the community.
c) Nutritional status of children?
d) Soci:-economic changes
e) Changes in Knowledge Attitude Practices in the community.
f) Acceptance by the community.
g) On going evaluation/terminal evaluation (for-projects)?
h) Decrease B.R. improvement of M.C.H. services?
i) Any other.
j) Who should evaluate? How can the community participate in
evaluation of CHW and in supervision and control of their
workers.
17. REMUNERATION: Workers are most often part-time and are expected
to devote 3-4 hours a day per month.
In the I.C.D.S.S. the workers are full-time drawing about Rs.100/to Rs.150/- per month.
In most other projects workers are paid Rs.3®/- to Rs.50/- per month.
The Govt. CW get Rs.200/- per month(full time during their initial
training) and Rs.50/- per month later on after their .initial training.
In R.A.H.A. and Plantations the workers are honorary. Evaluation of
^workers in most projects and PHCs, shows that the workers want higher
honorarium.
What population should each worker cover?
How many villages should he/she cover?
17.
i)
ii)
18.
Supervision:
a) Should the CHW be responsible to the village?
MHW's and PHC - M.O.?
b) Should village health committees be formed?
c) Should Block Development Officer supervise?
19.
a)
b)
c)
d)
Or the
should CHW's scheme be part of the PHC - set up?
Should it be independent?
What should be the interphase between the District Health
Authorities and other development authorities and CHW's?
What should be the interphase between the C.H.W. and the
community?
- 6 20.
a)
b)
21.
A)
b)
Should there he refresher training for the workers? How
frequently? For how long?
Should avenues for promotion and increment in wages be worked
out for CHW's? If so how?
How could medical colleges with the new schemes for take
over by 3 PHCs - take responsibility for the scheme?
Could they involve in the training of the workers and
evaluation of the scheme?
22. Primary health care envisages the involvement of health
department with various departments like agriculture social welfare
etc. in development of the community.
a) How could front line workers do-this?
b) Are the.doctors capable of functioning in unison with
other development agencies.
These are only a few facts about front line workers and a few
questions to stimulate discussions in view of what he have observed
in Jamkhed which perhaps is one of the best projects today. We
must attempt however to project how some of the things done here,
could be implemented in other pockets and parts of India.
Primary Health Care it has been said, marks the changing point which
a future historian would perhaps call the beginning of health"
revolution.
ft .
Let us all hope the future historian gets an opportunity to do this!
. .Contf'/zCOMi'"'JN!TY HEALTH CELL
. Marks Road
...COntd/3-
...3/-
*. r r.ust he-p in rind the rerlica-i lity of- our he alth
•:■
$«
c should - f atle t o demonstrate a pattern
of healV care vhick
practicable art- effectivc-jt after 50 years, hut for i.r next five year plan.
Thue our efforts should have nation®! •■ levanes. ’.'.t
have ■;,•-tec our opportunity if our he-olth. services and fr: rrfence can
not
multiplied and does not have any relevance for the-creation of
<■; ■relive hr alt’-; services on a country-hide bae-is.
5• Cor.rdi;:®!!'.':!:
ftp .•t--.tr H<a^h Organisation:
hr a’th is a i/totr subject.
’..c should avoid dual c-.ntrol «r parallel and competisv;
th inlstry one ■' ■■ 1 strict Chief tdical
leer.
<■ should
'clear
*
;
ceine our res-rct iv- roles a-.r establish clear channels of
co -oidr s-.io.o- and coopt ratio.”.
rroarily, our Ian for cotr^unity health services should
follow the stat
.
*
rv.tte-rn. ’? car; till in ’he lacunae and r.: rent-then
vfc'. .'ink, ’ ut v,t size-id nut drastically after !l-.f overall health plan
or health strategy.
'f rywise w orjoin face the risk of •■.astlnc our
erpertunity and luf.i-.y all .reIcvarcc.
* 'dtiHsatiQ-.
They include;
4rj
fiv wft r>>srr=rcllsny
corner.. ty■:■. coerces:
.edirr w
.s
*
anti hxceorathlc practitioners Ordinary simple
ho"e rrmedic s.
'i'ht cursor, lore ar.'.’ cricx’caii iccipcs Yoca.
health praciicrs of ot.:r people, ouch as p■ rs-onal clranlireor., 1 oilinc of milk, rf.r.t
e diof children self
r-t lianr
*
etc.
Local cducatri younc r rn n:rc vn:nen, including teachers,
■■oet-ran etc.., th,-;t can !r ropre' in ior various tyres
w* '‘heir-" that co- r« to vil'>’r - -- fa^wtrophy of local
Ir.edcrsbip ere initiative and for.- f fr.’V an attitude of
dependance and passive acccrtancc.
c nuct Guard againr-l
■hr tendency to pull t:»orlc up ly their cars, instrac'
of ere uraging them to pull the selv-s up ** y their
! no-;n—-trans.
c she Id resist a.'l veil inientloned
effort to sro »nfr ■ c: the people.
... .Cor tc74-
Instead,
sho .'Id encourage local leadership, local
initiative and self reliance. At a practical level,
we sbo-ald select suitable educat’d young vvtoacrfror- i hr vil 1’•■<;? c -r<<■<■- elves, and "air: then as health
workers. ' c s'; old also involve the community in all
health ’ ek ■, ■•.I-,'/' frOlB th< Stag
*
si planning ’rm., ac i .
9.
:--o- nunity ■ a rticipation:
A co. ;-unity should consider the health services as
heir ov-n. C immunity participation if.’ > he sine cua
non of any ruccrssful co-.- unity rroigrant, c. This is
:w re-ae.-jn why the co• ••unity must pay f 'r its health Kiwis
services partly, if not wholly.
The community .u-: t l-e involved in all stares of the
community health proera -r. including decision -:aking.
Irr-ortant vtf.y. of cor .unity • r.rticiration;
*
planning
Financial centricutions.
"election of workers irom the community
*
’ valuation of their work.
Vilace :tea 1th Corad-t■ ecs can play a very useful role
h'Tc, as aTready rirntionrd.
-• '‘•’'caal noir of ! fen J th r e □■•:::■. fc-n:
■’calth education i'- essential in a denneratJe set-up in
order 'o elicit ike willing ar.d enlightened cooperation of the people
rt increases retries cjr.prtcr.ce to look after their own
hr-ith, thus foe/-.rxing self-reliance.
It helps people take nregt.-r inter-st -.n their health
It jr'l; * .'cjplr identify incompetent workers or incorr
ect 'v.-:L".!Xe s.
’ verydody is interested in the’working of his/her ' ndy,
and in health. They i1! 'ay at .r. tion if health education is imagin
atively carried :ut, using, for eye :gle puppt s’-aws, one act plays,
prac-ical deconstrations, .wlilc exhibitions, etc.
The *
-follcr/r,
topics should ic epyrred;
first-aid
‘■ir^^lc nursinc
’ ody ''.f'owlr-dge
..........Contd/5-
5/Yo< a
hygirni
falancrd r'iet
Tosr pimple f rev-
12 , ’
- f c:
Vg I,.;, irr.rn'i. *
hc :>■-.'r-unlty j?alth fro-iraKrar -jI-Jrctivcs?
7a create r: -t-n hr nr/ v»- 1: <--grat?d com unity health
services for -hr total population of defined rural arras,
'
-'-K'-ssl<3<c orrvukf roUc e; roups ano on .?Tf v<. -triion.
: "
< should '■r
‘‘f availal 'an aJw i<- ci bagis
alone- lib <■ f factive r«f--'_'rel facilities.
1.
p,
fcr
/ ccinc-w-.d'-.c- a/ evyral ’
'o. rSer^r? r"rh3-ji?
'
*
’ <■
C ?«titutir a •
nine an< i lemc-ntatlon
*
Cor-^nit'- r-yalth '
.
Com
-.r-
3. ''rircilcn of suite > -.r? *. c - arc.-- of e.ork, Cc lection
ci’it .ria ,-Jrrw?; r.rntior.rc? in ’h: rrivral a; roach.
4. ”■ ?. -pvc’v
area(s) to eJe f n' i->r -•no’-'’. -:■•■■■ nnd essrts.
This will involve- nlgn •’•:.■• an<;! conducti .'0 of surveys cover
in-full'Jv.ir.' varioles:
r'-.rtorva’-hic
-■or. Tj-r co.-:pnic
Hee? th “ Pristine ord’It tits
-> ' xi«t l.-p facil v ic g
.......... .Cbntd/6-
1
“• Flaminc:
6.
- :■' • ;t-y. ‘o.? ;
i'rr Aeration of r-rrlininary plan
f incursions
radjustmc'c-tfi
l iralizc iion of -he I road - Ian
''election and iraininr ofwrkrrs
; uiSdir-'-, one furnish.} nn of J-.or-.-i tai-., health
erntrre etc.,
’"--oned ’ rrlnt'iw of h«-aVh services
7. ' cox 5
3.
id ■•■..■ :v< - ■■:at ention.
' '•a’tta' lor of ■’»"wnity
' ■ .•
Ihi •’
•■•. ■ ■ ;•
C-
. -■rv.’.cf s —• both concv•• : *.■•••.. ane!
. |
o:
Ilannlnc
i'5roEra:
-.xnc
*
r valua'i ion.
«
(Voluntary ?'r-.ltb - rll)
ion
♦
■
♦
vrrparcc' by Fr..!.' .Gill
Asst.Frof.Crnt.7r for
'om'runity "■ die ire
Al'
frv; frlhi
7^
THE VILLAGE HEALTH WORKER LACKEY OR LIBERATOR?
David Bradford Werner
Director, Hesperian Foundation
P.O. Box 1692
Palo Alto, California 94302, U.S.A.
Prepared for:
International Hospital Federation Congress
Sessions on Health Auxiliaries and the Health Team
Tokyo, Japan
22-27 May, 1977
THE VILLAGE HEALTH WORKER - LACKEY OR LIBERATOR?
-- David Werner —
1977
Throughout Latin America, the programmed use of health auxiliaries has,
in recent years, become an important part of the new international push of
'community oriented' health care. But in Latin America village health workers
are far from new. Various religious groups and non-government agencies have
been training promotores de salud or health promoters for decades. And to a
large (but diminishing) extent, villagers still rely, as they always have,
on their local curanderos, herb doctors, bone setters, traditional midwives
and spiritual healers. More recently, the medico practicante or empirical
doctor has assumed in the villages the same role of self-made practitioner and
prescriber of drugs that the neighborhood pharmacist has assumed in larger
towns and cities.
Until recently, however, the respective Health Departments of Latin America
have either ignored or tried to stamp out this motley work force of non
professional healers. Yet the Health Departments have had trouble coming up
with viable alternatives. Their Western-style, city-bred and city-trained
M.D.s not only proved uneconomical in terms of cost effectiveness; they flatly
refused to serve in the rural area.
The first official attempt at a solution was, of course, to produce more
doctors. In Mexico the National University began to recruit 5000 new medical
students per year (and still does so). The result was a surplus of poorly
trained doctors who stayed in the cities.
The next attempt was through compulsory social service. Graduating
medical students were required (unless they bought their way off) to spend a
year in a rural health center before receiving their licenses. The young
doctors were unprepared either by training or disposition to cope with the
health needs in the rural area. With discouraging frequency they became
resentful, irresponsible or blatantly corrupt.
Next came the era of the mobile clinics. They, too, failed miserably.
They created dependency and expectation without providing continuity of service.
The net result was to undermine the people's capacity for self care.
It was becoming increasingly clear that provision of health care in the
rural area could never be accomplished by professionals alone. But the medical
establishment was--and still is--reluctant to crack its legal monopoly.
At long last, and with considerable financial cajoling from foreign and
international health and development agencies, the various health departments
have begun to train and utilize auxiliaries. Today, in countries where they
have been given half a chance, auxiliaries play an important role in the health
care of rural and periurban communities. And if given a whole chance, their
impact could be far greater. But, to a large extent, politics and the medical
establishment still stand in the way.
2
My own experience in rural health care has mostly been in a remote
mountainous sector of Western Mexico, where, for the past 12 years I have been
involved in training local village health workers, and in helping foster a
primary health care network, run by the villagers themselves. As the villagers
have taken over full responsibility for the management and planning of their
program, I have been phasing out my own participation to the point where I
am now only an intermittent advisor. This has given me time to look more
closely at what is happening in rural health care in other parts of Latin
Ameri ca.
Last year a group of my co-workers and I visited nearly 40 rural health
projects, both government and non-government, in nine Latin American countries
(Mexico, Guatemala, Honduras, El Salvador, Nicaragua, Costa Rica, Venezuela,
Colombia and Ecuador.) Our objective has been to encourage a dialogue among
the various groups, as well as to try to draw together many respective
approaches, methods, insights and problems into a sort of field guide for
health planners and educators, so we can all learn from each other's experience.
We specifically chose to visit projects or programs which were making signifi
cant use of local, modestly trained health workers or which were reportedly
trying to involve people more effectively in their own health care.
We were inspired by some of the things we saw, and profoundly disturbed
by others. While in some of the projects we visited, people were in fact
regarded as a resource to control disease, in others we had the sickening
impression that disease was being used as a resource to control people. We
began to look at different programs, and functions, in terms of where they lay
along a continuum between two poles: community supportive and community
oppressive.
Community supportive programs or functions are those which favorably
influence the long-range welfare of the community, that help it stand on its own
feet, that genuinely encourage responsibility, initiative, decision making and
self-reliance at the community level, that build upon human dignity.
Community oppressive programs or functions are those which, while invariably
giving lip service to the above aspects of community input, are fundamentally
authoritarian,paternalistic or are structured and carried out in such a way
that they effectively encourage greater dependency, servility and unquestioning
acceptance of outside regulations and decisions; those which in the long run
are cripplong to the dynamics of the community.
It is disturbing to note that, with certain exceptions, the programs
which we found to be more community supportive were small non-government efforts,
usually operating on a shoestring and with a more or Tess sub-rosa status.
As for the large regional or national programs-- for all their international
funding, top-ranking foreign consultants and glossy bilingual brochures
portraying community participation-- we found that when it came down to the
nitty-gritty of what was going on in the field, there was usually a minimum of
effective community involvement and a maximum of dependency-creating handouts,
paternalism and superimposed, initiative destroying norms.
I don't have time to elaborate here, but anyone who is interested in a
more detailed account of community supportive and oppressive health programming
may send for a copy of a paper I presented in England last year entitled
3
Health Care and Human Dignity.
*
In our visits to the many rural health programs in Latin America, we
found that primary health workers come in a confusing array of types and
titles. Generally speaking, however, they fall into two major groups:
auxiliary nurses
or health technicians
health promoters
or village health workers
--at least primary education
plus 1 - 2 years training
--average of 3rd grade education
plus 1 - 6 months training
—usually from outside the community
--usually from the community
and selected by it
--usually employed full time
--salary usually paid by the program
(not by the community)
—often a part time health worker
supported in part by farm labor
or with help from the community
--may be someone who has already
been a traditional healer
In addition to the health workers just described, many Latin American
countries have programs'to provide minimal training and supervision of
traditional midwives.- Unfortunately, Health Departments tend to refer to
these programs as 'Control de Parteras Empiricas'--Control of Empirical
Midwives--a terminology which too often reflects an attitude. Thus to
Mosquito Control and Leprosy Control has been added Midwife Control. (Small
wonder so many midwives are reticent to participate!) Once again, we found
the most promising work with village midwives took place in small non-government programs. In one such program
**
the midwives had formed their own club
and organized trips to hospital maternity wards to increase their knowledge.
What skills can the village health worker perform? How well does he per
form them? What are the limiting factors that determine what he can do? These
were some of our key questions when we visited diferent rural health programs.
We found that the skills which village health workers actually performed
varied enormously from program to program. In some, local health workers with
minimal formal education were able to perform with remarkable competence a
wide variety of skills embracing both curative and preventive medicine as well
as agricultural extension, village cooperatives and other aspects of community
education and mobilization. In other programs--often those sponsored by Health
Departments--village workers were permitted to do discouragingly little. Safe
guarding the medical profession's monopoly on curative medicine by using the
standard argument that prevention is more important than cure (which it may be
to us but clearly is not to a mother when her child is sick) instructors often
taught these health workers fewer medical skills than many villagers had
already mastered for themselves. This sometimes so reducedthe people's respect
^Health Care and Human Dignity by David Werner. 1976. Available through the
Hesperian Foundation, P.O. Box 1692, Palo Alto, California 94302 U.S.A.
Please send $2,00 U.S. to cover copy and postage.
**In Pinalejo, Honduras.
for their health worker that he (or usually she) became less effective, even
in preventive measures.
In the majority of cases,we found that external factors, far more than
intrinsic factors, proved to be the determinants of what the primary health
worker could do. (See Outline 1.) We concluded that the great variation in
range and type of skills performed by village health workers in different
programs has less to do with the personal potentials, local conditions or avail
able funding than it has to do with the preconceived attitudes and biases of
health program planners, consultants and instructors. In spite of the often
repeated eulogies about "primary decision making by the communities themselves",
seldom do the villagers have much, if any, say in what their health worker is taught
and told to do.
The limitations and potentials of the village health worker--what he is
permitted to do and, conversely, what he could do if permitted--can best be
understood if we look at his role in its social and political context. In
Latin America, as in many other parts of the world, poor nutrition, poor hygiene,
low literacy and high fertility help account for the high morbidity and mortality of
the impoverished masses. But as we all know, the underlying cause--or more exactly,
the primary disease--is ineguity: inequity of wealth, of land,of educational
opportunity, of political representation and of basic human rights. Such
inequities undermine the capacity of the peasantry for self care. As a result,
the political/economic powers-that-be assume an increasingly paternalistic stand,
under which the rural poor become the politically voiceless recipients of both
aid and exploitation. (See Figure 3.) In spite of national, foreign and inter
5
national gestures at aid and development, in Latin America the rich continue to
grow richer and the poor poorer. As anyone who has broken bread with villagers
or slum dwellers knows only too well: health of the people is far more influenced
by politics and power groups, by distribution of land and wealth, than it is by
treatment or prevention of disease.
Political factors unquestionably comprise one of the major obstacles to a
community supportive program. This can be as true for village politics as for
national politics. However, the politico-economic structure of the country must
necessarily influence the extent to which its rural health program is community
supportive or not.
Let us consider the implications in the training and function of a primary
health worker:
If the village health worker is taught a respectable range of skills,
if he is encouraged to think, to take initiative and to keep learning on his
own, if his judgment is respected, if his limits are determined by what he
knows and can do, if his supervision is supportive and educational, chances
are he will work with energy and dedication, will make a major contribution
to his community and will win his people's confidence and love. His example
will serve as a role model to his neighbors, that they too can learn new
skills and assume new responsibilities, that self-improvement is possible.
Thus the village health worker becomes an internal agent-of-change, not only
for health care, but for the awakening of his people to their human potential. . .
and ultimately to their human rights.
However, in countries where social and land reforms are sorely needed,
where oppression of the poor and gross disparity of wealth is taken for granted,
and where the medical and political establishments jealously covet their power,
it is possible that the health worker I have just described knows and does
and thinks too much. Such men are dangerous! They are the germ of social
change.
So we find, in certain programs, a different breed of village health
worker is being molded . . . one who is taught a pathetically limited range of
skills, who is trained not to think, but to follow a list of very specific
instructions or 'norms', who has a neat uniform, a handsome diploma and who
works in a standardized cement block health post, whose supervision is
restrictive and whose limitations are rigidly predefined. Such a health
worker has a limited impact on the health and even less on the growth of the
community. He--or more usually she--spends much of her time filling out
forms.
In a conference I attended in Washington last December, on Appropriate
Technology in Health in Developing Countries, it was suggested that "Technology
can only be considered appropriate if it helps lead to a^ change in the distri
bution of wealth and power.” If our goal is truly to get at the root of
human iTTs, must we not also recognize that, likewise, health projects and
health workers are appropriate only if they help bring about a healthier
distribution of wealth and power?
6
Outline 1
Factors that Influence What a Primary Health Worker Can Do
Intrinsic factors
—cultural background
--level of literacy
—personal factors
compassion
integrity
. judgment
initiative
perceptiveness
special talents
learning capacity
—acceptance of VHW and
program by community
factors
influencing
personal
■potential
of VHW
outside
decisions
and
control
Extrinsic factors
--attitudes,open or preconceived,as to
what the VHW should be taught and
permi tted to do
--length,content,quality and appropriate
ness of training
--limitations of 'norms' imposed on
health worker by outside authorities
(e.g. Heal th Dept.)
--ability or inability of instructors and
supervisors to build upon the existing
knowledge, skills and cultural
perspectives of the VHW.
What the health worker can do is too often limited by external factors
(doctors and politics) rather than determined by his personal capabilities
and potent iaI.
7
Too often aid and exploitation go hand in hand.
Fig. 3
WE FEEL IT OUR
MORAL DUTY TO HELP
THE POOR STAND ON
THEIR OWN FEET.4’
Aid
enden Ce
(
COULD IT BE A
VICIOUS CIRCLE?
Increased aid
[with strings
attached)
Increased dependency
Stronger central power
of poor on rich, of rural
(national, foreign,
community on central govt.
multinational)
and of central govt, on
Weaker people
t!
foreign
and multilateral
agencies.
1
Increased
debt
(poor owe rich)
THE
AID
CYCLE
\
1 V
Humiliation, decreased
dignity, increased
irresponsibility, sense
of futility, misdirected
anger.
\ \
Increased
exploi tation
Increased outside
manipulation and control
8
We say prevention is more important than cure.
willing to go? Consider diarrhea:
But how far are we
Each year millions of peasant children die of diarrhea. We tend to
agree that most of these deaths could be prevented. Yet diarrhea remains the
number one killer of infants in Latin America and much of the developing
world. Does this mean our so-called 'preventive' measures are merely
palliative? At what point in the chain of causes which makes death from
diarrhea a global problem (see Outline #2) are we coming to grips with the
real underlying cause. Do we do it . . .
...by preventing some deaths through treatment of diarrhea?
...by trying to interrupt the infectious cycle through construction of
latrines and water systems?
...by reducing high risk from diarrhea through better nutrition?
...or by curbing land tenure inequities through land reform?
Land reform comes closest to the real problem. But the peasantry is
oppressed by far more inequities than those of land tenure. Both causing and
perpetuating these crushing inequities looms the existing power structure:
local, national, foreign and multinational. It includes political, commercial
and religious power groups as well as the legal profession and the medical
establishment. In short it includes . . . ourselves.
As the ultimate link in the causal chain which leads from the hungry
child with diarrhea to the legalized inequities of those in power, we come
face to face with the tragic flaw in our otherwise human nature, namely greed.
Where, then, should prevention begin? Beyond doubt, anything we can do
to minimize the inequities perpetuated by the existing power structure will
do far more to reduce high infant mortality than all our conventional preventive
measures put together. We should, perhaps, carry on with our latrine
building rituals, nutrition centers and agricultural extension projects.
But let's stop calling it prevention. We are still only treating symptoms.
And unless we are very careful, we may even be making the underlying problem
worse . . . through increasing dependency on outside aid, technology and
control.
But this need not be the case. If the building of latrines brings
people together and helps them look ahead, if a nutrition center is built
and run by the community and fosters self-reliance, and if agricultural
extension, rather than imposing outside technology encourages internal growth
of the people toward more effective understanding and use of their land, their
potentials and their rights . . . then, and only then, do latrines, nutrition
centers and so-called extension work begin to deal with the real causes of
preventable sickness and death.
This is where the village health worker comes in. It doesn't matter
much if he spends more time treating diarrhea than building latrines. Both
are merely palliative in view of the larger problem. What matters is that
he get his people working together.
Yes, the most important role of the village health worker is preventive.
But preventive in the fullest sense, in the sense that he help put an end to
oppressive inequities, in the sense that he help his people, as individuals
9
Outline #2
EFFECT
WE SAY PREVENTION IS MORE IMPORTANT THAN CURE—
BUT WHERE SHOULD PREVENTION BEGIN?
Needless Suffering and Dehumanization
Disproportionately high morbidity and mortality
(especially infants, mothers, and young men)
Infections, such as diarrheas and pneumonia, violence, etc,
Poor nutrition, poor hygiene; low literacy, high fertility
Low initiative, misdirected anger
t
Inequity of:
Wealth
land
Health Care —
Education
Representation
Human Rights
<5
A
y
THE
AID
CYCLE
4
^.'oidx3.
Existing Power Structure **
-financial power groups
-political power groups
-medical establishment
-legal profession
-religious power groups,
''Private
Governmental
Foreign
Multinational
(short sighted
self-interest)
CAUSE
PREVENTIVE
MEASURES;
Social reform
(or revolution)
Humanization
(Evolution)
10
and as a community, liberate themselves not only from outside exploitation
and oppression, but from their own short-sightedness, futility and greed.
The chief role of the village health worker, at his best, is that of
liberator. This does not mean he is a revolutionary (although he may be
pushed into that position). His interest is the welfare of his people.
And, as Latin America's blood-streaked history bears witness, revolution
without evolution too often means trading one oppressive power group for
another. Clearly, any viable answer to the abuses of man by man can only
come through evolution, in all of us, toward human relations which are no
longer founded on short-sighted self-interest, but rather on tolerance,
sharing and compassion.
I know it sounds like I am dreaming. But the exciting thing in Latin
America is that there already exist a few programs that are actually working
toward making these things happen—where health care for and by the people
is important, but where the main role of the primary health worker is to
assist in the humanization or, to use Paulo Freire's term, conscientizacion
of his people.
Before closing let me try to clear up some common misconceptions.
Many persons still tend to think of the primary health worker as a
temporary second-best substitute for the doctor . . . that if it were finan
cially feasible the peasantry would be better off with more doctors and fewer
primary health workers.
I disagree. After twelve years working and learning from village
health workers--and dealing with doctors—I have come to realize that the
role of the village health worker is not only very distinct from that of
the doctor, but, in terms of health and well-being of a given community,
is far more important. (See appendix.)
You may notice I have shied away from calling the primary health
worker an 'auxiliary'. Rather I think of him as the primary member of the
health team. Not only is he willing to work on the front line of health
care, where the needs are greatest, but his job is more difficult than that
of the average doctor. And his skills are more varied. Whereas the doctor
can limit himself to diagnosis and treatment of individual 'cases', the
health worker's concern is not only for individuals—as people—but with
the whole community. He must not only answer to his people's immediate
needs, but he must also help them look ahead, and work together to overcome
oppression and to stop sickness before it starts. His responsibility is to
share rather than hoard his knowledge, not only because informed self-care
is more health conducing than ignorance and dependence, but because the
principle of sharing is basic to the well-being of man.
Perhaps the most important difference between the village health worker
and the doctor is that the health worker's background and training, as well
as his membership in and selection by the community, help reenforce his will
to serve rather than bleed his people. This is not to say that the village
health worker cannot become money-hungry and corrupt. After all, he is as
human as the rest of us. It is simply to say that for the village health
11
The primary health worker
lives and works at the
level of the people.
His first job is to share
his knowledge.
(Illustration from the
forthcoming English
edition of Where There is
No Doctor by David Werner)
worker the privilege to grow fat off the illness and misfortune of his
fellow man has still not become socially acceptable.
Forgive me if I seem a little bitter, but when you live with and share
the lot of Mexican villagers for 12 years, you can't help but feel a
little uncomfortable about the exploits of the medical profession. For
example, Martin, the chief village medic and coordinator of the villager
run health program I helped to start, recently had to transport his brother
to the big city for emergency surgery. His brother had been shot in the
stomach. Now Martin, as a village health worker supported through the
community, earns 1,600 pesos ($80.00) a month, which is in line with what
the other villagers earn. But the surgeon charged 20,000 pesos ($1000.00)
for two hours of surgery. Martin is stuck with the bill. That means he
has to forsake his position in the health program and work for two months
as a wet-back in the States--!n order to pay for two hours of the surgeon's
time. Now, is that fair?
*
*
*
No, the village health worker, at his best, is neither choreboy nor
auxiliary nor doctor's substitute. His commitment is not to assist the
doctor, but to help his people.
The day must come when we look at the primary health worker as the key
member of the health team, and at the doctor as the auxiliary. The doctor,
as a specialist in advanced curative technology, would be on call as needed
12
by the primary health worker for referrals and advice. He would attend
those 2 - 3% of illnesses which lie beyond the capacity of an informed people
and their health worker, and he even might, under supportive supervision,
help out in the training of the primary health worker in that narrow
area of health care called Medicine.
Health care will only become equitable when the skills pyramid has
been tipped on its side, so that the primary health worker takes the lead,
and so that the doctor is on tap and not on top.
TIPPING THE HEALTH MANPOWER PYRAMID ON ITS SIDE
THE TYPICAL PYRAMID
The community is on the bottom
of the stack.
Each-level is
rigidly delineated.
THE PYRAMID AS IT SHOULD BE
The comnunity health worker
assumes the lead role in the
health team.
Appendix
COMPARISON OF THE MEDICAL DOCTOR AND THE PRIMARY HEALTH WORKER
(Note: The medical doctor as described here is the typical Western-style M.D.
as produced by medical schools in Latin America. Clearly, there are exceptions.
Most Latin American medical schools are beginning to modify their curricula to
place greater emphasis on community health. However, not modifications but
radical changes, both in selection and training, are needed if doctors are
ever to become an integrated and fully positive part of a health team that
serves all the people.)
CONVENTIONAL DOCTOR
VILLAGE HEALTH WORKER
(at his best)
Class
Background
Usually upper middle
class.
From the peasantry.
How chosen
By medical school for:
grade point average; eco
nomic and social status.
By community for: interest,
compassion, knowledge of
community, etc.
Preparation
Mainly institutional, 12-16
years general schooling,
4-6 years medical training.
Training concentrates on
•physical and technolo
gical aspects of medicine,
•and gives low priority to
human, social, and poli
tical aspects. (This is
now changing in some medi
cal schools.)
Mainly experiential.
Limited, key training appro
priate to serve all the
people in a given community:
•Dx & Rx of important disease
•Preventive medicine
•Community health
•Teaching skills
•Health care in terms of eco
nomic and social reali
ties, and of needs (felt
and long term) of both in
dividuals and the community.
®Humanization (conscientizacion) and group dynamics
Qualifications
Highly qualified to diagnose
and treat individual cases.
Especially qualified to
manage uncommon and diffi
cult diseases.
Less qualified to deal ef
fectively with most impor
tant diseases of most peo
ple in a given community.
Poorly qualified to supervise
and teach VHW. (Well qua
lified in clinical medi
cine, but not in other more
important aspects of health
care; he tends to favor im
balance; wrong priorities.)
More qualified than doctor to
deal effectively with the
important sicknesses of most
of the people.
Non-academic qualifications are:
Intimate knowledge of the
community, language, cus
toms, attitudes toward
sickness and healing.
Willingness to work and earn
at the level of the commu
nity, where the needs are
greatest.
Not qualified to diagnose and
treat certain difficult and
unusual problems; must refer.
14
CONVENTIONAL DOCTOR
VILLAGE HEALTH WORKER
______ (at his best)___________
Orientation
Disease/Treatment/
Individual patient ori
ented.
Health/Community oriented.
Seeks a balance between cura
tive and preventive. (Cura
tive to meet felt needs,
preventive to meet real
needs.)
Primary Job
Interest
The challenging and inte
resting cases. (Often
bored by day to day
problems.)
Helping people resolve their
biggest problems because he
is their friend and neighbor.
Superior. Treats people as
On their level. Treats patients
patients. Turns people into
as people.
1 cases'
,-----------------------------------------------------Underestimates people's capa- /Mutual concern and interest becity for self-care.
/
cause the VHW is village------------------------------------------ ------------------------------------ (
seiected.
Attitude of the Hold him in awe. Blind trust '-----------------------------------------------------sick toward
(or sometimes distrust).
See him as a friend. Trust him
M.D. or VHW
as a person, but feel free to
question him.
Attitude toward
the sick
How does he use
Medical
Knowledge?
Hoards it.
Delivers 'services', dis
courages self-care, keeps
patients helpless and de
pendent.
Shares it.
Encourages informed self-care,
helps the sick and family
understand and manage prob
lems.
Accessibility
Often inaccessible, especially
to poor.
Preferential treatment of
haves over have-nots.
Does some charity work.
Very accessible.
Lives right in village.
Low charges for services.
Treats everyone equally and as
his equal.
Consideration
for economic
factors
Overcharges.
Expects disproportionately
high earnings.
Feels it is his God-given
right to live in luxury
while others hunger.
Often prescribes unnecessari
ly costly drugs.
Overprescribes.
Reasonable charges.
Takes the person's economic
position into account.
Content (or resigned) to live
at economic level of his
people.
■ Perscribes only useful .drugs.
Considers cost. Encourages
effective home remedies.
Relative
Permanence
At most spends 1-2 years in a
rural area and then moves
to the city.
A permanent member of the com
munity .
15
CONVENTIONAL DOCTOR
VILLAGE HEALTH WORKER
(at his best)
Continuity of
Care
Can't follow up cases because he doesn't live in
the isolated areas.
Visits his neighbors in their
homes to make sure they get
better and learn how not to
get sick again.
Cost
Effectiveness
Too expensive to ever meet
medical needs of the poor-unless used as an auxiliary
resource for problems not
readily managed by VHW.
Low cost of both training and
practice.
Higher effectiveness than doc
tor in coping with primary
problems.
Resource
Requirements
Hospital or health center.
Depends on expensive, hardto-get equipment and a
large subservient staff to
work at full potential.
Works out of home or simple
structure.
People are the main resource.
Present Role
On top.
Directs the health team.
Manages all kinds of medical
problems, easy or complex.
Often overburdened with easily treated or preventable
illness.
On the bottom.
Often given minimal responsibility, especially in medicine.
Regarded as an auxiliary
(lackey) to the physician.
Impact on the
Community
Relatively low (in part
negative).
Sustains class differences,
mystification of medicine,
dependency on expensive
outside resources.
Drains resources of poor
(money).
Potentially high.
Awakening of people to cope more
effectively with health needs,
human needs, and ultimately
human rights.
Helps community to use resources
more effectively.
Appropriate
(future?)
Role
On tap (not on top).
Functions as an auxiliary to
the VHW, helping to teach
him more medical skills and
attending referrals at the
VHW's request. (The 2-3%
of cases that are beyond
the VHW's limits.)
He is an equal member of the
health team.
Recognized as the key member of
the health team.
Assumes leadership of health
care activities in his village, but relies on advice,
support, and referral assistance from the doctor when
he needs it.
He is the doctor's equal (although his earnings remain
in line with those of his
fellow villagers).
16
TWO
APPROACHES
TO
HEALTH
CARE
VILLAGE HEALTH WORKERS
CAN HELP DOCTORS LEARN
THE SECOND APPROACH
HEALTH SCIENCES
Effective Health Care for All .* is the slogan of the
seventies and great strides are being taken all over the
world in the development of alternative approaches in
•Health Care Delivery
*
so that Health which has been
defined by the World Health Organisation as "a state of
complete physical, mental and social wellbeing” may
become a reality to the millions in the developing and
developed world.
The Health Sciences have advanced
greatly in recent years and the challenge today, lies in
making the scientific medical knowledge, available to the
common man in the rural and urban areas so that he can begur
to participate in the process of breaking out of the vicious
cycle of poverty, malnutrition and disease.
This challenge has three important components a) The development of appropriate health Care programmes
and delivery systems uhich have evolved out of a close
interaction of modern medical knowledge and the local
economic, socio-cultural and manpower resources.
b) The development of an 'appropriate
*
health care
technology which includes cheaper drugs and simple but
scientific equipment and processes.
c)
The development of an 'appropriate communication
technology* by which the components of a) health care
programmes and b) health care technology are made common
knowledge so that the people, having been equipped with
this knowledge will then actively participate in the
planning, organisation, management and evaluation of
: 2 :
their own health programmes.
The word ’appropriate’ here
has been used to signify that which is scientific but
economical; that which is based on indigenous local resources;
that which is suited to the technical level of the user;
that which does not create major cross-cultural conflicts.
This column of science for the villages will in future
be devoted to the discussion of all innovative approaches
and ’technologies’ that have evolved in the developing
world in general and the Indian scene in particular.
We see Health Care as an integral part of rural development
and we are convinced that all development workers have in
one way or the other to deal with health issues in their
work.
This column will therefore attempt to create a link
between the development workers who have community health
problems and related issues to deal within the field and
the research institutions and field projects where solutions
and suggestions to tackle these issues are being researched.
We must all begun to adopt a new research technigue and i.e.
’Go to the people,
Live with them,
Love them,
Serve them,
Start with what they have
Build upon what they know’
and we hope that this column will keep you in touch with
the important and relevant answers arising out of this
new technique.
We invite all our readers to send us their
suggestions and experiences for this column.
...3/-
: 3 :
In issues Nos 4,5 and 6 of volume 1 we published a
tentative list of frontline&s in health care in the country.
This was not expected to be a complete and exhaustive list
since from time to time we come in touch with more and more
projects.
If any groups were left out, this was uninten
tional and when we know of them we shall include them in a
supplementary list that will be published soon.
In this issue we have begun a bibliography of reference
material from India and abroad pertaining to community
health.
This list is again not exhaustive but only an
indicationof the type of material that is already available
in this field.
Here again we would be glad to hear from
any of our readers of any other material that they have
found useful.
///////
Book Review
Alternative Approaches To Health Care: Pub
lished by the Indian Council of Medical
Research and the Indian Council for Social
Science Research; Pages 242.
a feasible proposition in the existing social and
administrative structure, iii) health education
and school health in villages are matters which
must receive immediate attention.
The symposium also emphasized the need for
maximum utilisation of existing resources rather
than duplication or under utilisation.
The symposium rightly recommends that the
HIS volume is the report of a symposium
rural health care models must be given
Torganised jointly by the ICMR and the aexisting
fair trial. It does not, however, seem to have
ICSSR at the National Institute of Nutrition, realised that this cannot happen as long as 70
Hyderabad, in October, 1976 at which on-going
operation research projects in the field of health
care were discussed. Some 16 health care projects
are described and eight more have been discussed
in brief.
per cent to 80 per cent of our health budget con
tinues to be spent in urban areas and a majo
rity of that on big hospitals and super-specialised
centres of excellence in medical care, teaching
and research—the so-called 'disease palaces’.
20
- 5uu 001
The papers in the book may be broadly classi
Everybody seems to be asking for more funds
fied under four major heads : i) Projects relating to improve the health care system. On the con
to nutrition and integrated child health care, trary, what is needed is the reorganisation of
ii) Hospital-based project, (iii) Comprehensive the whole health care structure; to change the
rural health projects, and iv) Projects on the basis priorities from a hospital-based health care sys
of health cooperatives. All these projects have tem to a people-based health care programmes.
been much talked off in the recent times. Though Obviously this needs change at far deeper levels
there are many other on-going projects in the and the questions involved are complex. If only
country which have not been covered, the volume front line workers are supposed to work in the
serves as a useful compendium. This symposium existing framework without meaningful involve
must have affected the 'Jan Swasthya Rakshak ment of P.H.C. doctors and without any change
Yojna’ of the new health ministry as a number in the whole attitude towards the health care to
of suggestions made have obviously been adopted. the rural poor, the problem cannot be amelio
It is however ironical that the recommendations rated. In fact, under such circumstances the re
are almost similar to that made by the Bhore sources channelled will only go to help the vested
committee in 1946.
interests to continue their exploitation and main
tain the status quo.
Dr. Thimappaya’s paper has tried to identify
the needed areas of study, on the basis of the
The issue of community participation and moti
knowledge from these alternative models. The vation has not been discussed with sufficient
guidelines proposed by Dr. Kamla Gopal Rao to clarity. Though it is commendable that agencies
develop new models will be useful for those like the ICMR, NIHAE, and ICSSR came together
who wish to start new projects. Some of the im to discuss these important issues, it would have
portant conclusions of the symposium, are i) the been better had actual field workers with first
need for inclusion of safe water supply, sanitary hand experience in community participation and
latrines, and disposal of waste within the pur motivation also been invited to participate. How
view of health care programmes, ii) health intell ever the Hyderabad seminar is worthy of con
igence for communicable diseases cannot effec sideration.
—Narendra Mehrotra
tively work within the existing framework. Main
—Ravi Narayan.
tenance of health records in the family is also not
Voluntary Action
w
someone had gone on a vehicle to inform the
Jorhat Hospital. The crowd was gradually swel
ling to see the P.M. and I joked that "the public
meeting could be held here instead of Jorhat.”
It was only at the village I saw that the wound
on my right leg was quite deep and went down
to the bone. The villagers said 'Bhagavaner
leela’ (God’s play). I replied 'Bhagavaner kripa'
(God’s mercy). I even repeated a small couplet
from an Assamese devotional song that I knew
which meant God has saved us. When my wound
was being washed a woman from the village
offered some Dettol and another brought some
clean cloth. Morarjibhai suggested that it would
be good to keep a wet pack on the wound. Some
one asked 'why not urine?’ Morarjibhai said 'that
would be better’. I said 'why not my own.
Morarjibhai said 'that would be the best!’ So a
urine pack was put on my leg by Hasmukh Shah
and I was bandaged. At about 10 ’O’clock the
ambulances started arriving.
From the village 'Tekala Gaam’, Kantibhai
Desai and I were taken on an ambulance to the
Air Force Hospital at Jorhat. Each one of us was
checked at this hospital. I was given anaesthesia
at about 3 a.m. Later on I was given to under
stand that I had fractured one bone on the joint
of my left shoulder, another on the right wrist,
and a third one on the little finger of my right
hand. They had also put several stitches on the
right leg and that leg too was plastered. Luckily
there was no fracture there.
It was indeed a miraculous escape. While five
members of the crew gave their lives, the passen
gers were all saved. I had heard of forced land
ings where all the passengers would be saved
and of crashes where nobody would survive. But
there was an incident where five died and the
rest survived.
Morarjibhai’s luck was seen to be the greatest
because all those who died were only a few feet
ahead of him and all those who were injured,
were sitting a few feet behind him. Among those
December 1977
who were injured, we who were sitting on the
right hand side had serious injuries and those
who were on the left hand side got away with
very slight injuries. Here again Morarjibhai was
sitting on the right side but hardly sustained any
injuries at all. Among those who were injured
and survived I sustained maximum injuries but
that too was nothing compared to what could
have happened.
Now a few impressions on the whole event.
Composure and discipline were the two factors
that helped in.the evacuation from the aircraft.
Morarjibhai’s undisturbed attitude was exem
plary. He slept soundly as soon as he went to
bed, after being satisfied that everyone was being
looked after.
My own feeling was that of gratitude to God
for having been merciful on us. I was also
naturally happy to have escaped so narrowly
from what was certain death. These two feelings
kept me cheerful throughout. My cheerfulness
definitely helped me to tolerate the pang of the
injuries. It might have also helped me in the
healing process.
A Roman Catholic bishop and some nuns from
a nearby church came and prayed for me in front
of my bed. I requested them to read from the 13th
Corinthians and sing the hymn 'The Lord is my
Shepherd, I shall not want.’ A friend brought us
some Sikh devotional songs and another a selec
tion of bhajans. The religious atmosphere of
Bapu’s ashrams was revived in my memory.
Training in Bapu’s ashrams seemed to me to
be one of the factors that helped me most in
getting out of this ordeal, and I would rate faith,
hard living, sharing your comforts with your
neighbours, and appreciation of music as some
of the main aspects of this training.
My stitches were cut on November 14th and I
am recouping quite fast. The hospital discharged
me on November 25th. But it will take two to
three months for complete recovery.
19
A Model for Village Development
in Bangladesh
MD. AMINUL ISLAM
*
C AVE The Children Federation/Community
Development Foundation, an International
Community Development Agency, operates in the
U.S.A., Asia, Africa, Latin America, the Middle
East, and Europe, to help the children of the
Third World by helping them and their parents
to change their own communities for a better life.
In Bangladesh SCF/CDF began relief operations
after the devastating cyclone of 1970. Work con
tinued through 1971 and then in early 1972 as
assistance to wartorn refugees. As the critical
need for relief subsided, SCF/CDF started housing
projects in Chittagong and assisted in irrigation *
for rice cultivation, adult literacy, and road con
struction programmes there.
After 1972 we began a new programme called
Community-Based Integrated Rural Development
(CBIRD), in three villages in Rangunia Thana,
Chittagong District. This programme, now expan
ded to nine villages of four thanas (Rangunia Chittagong; Mirjapur - Tangail; Ghior - Dacca;
and Nasirnagar-Comilla) is serving a population of
over 31,000 people in close cooperation with the
Local Government and Rural Development and
Cooperatives Ministry, Government of Bangla
desh.
ii) To develop the incentive for cost-effective
appropriately scaled programmes in agri
culture, health services, education, and other
activities of social and economic benefit;
iii)To encourage development of local finan
cial networks and investment policies which
recycle the added income of the rural poor
back into the economy of the target popu
lation;
iv)To comprehensively attack the basic defi
ciencies of the target population through an
integration of component services rather
than through a single specialized empha
sis;
v) To involve local target communities with
appropriate regional and national agencies
and institutions at the time when such lin
kages are necessary for further develop
ment.
vi) To work on experimental basis for establi
shing a model of Community-Based Inte
grated Rural Development (CBIRD) and to
sell the idea to the National Government
for replicating.
In beginnning a new village programme the
first task is to arrange for the villagers to elect
a Village Development Committee (VDC). This
The agency’s programmes carry out a model Committee is generally composed of a cross sec
of development which relies on the ability of tion of village people such as, farmers, landless
rural people to make their own decisions, aided by . cultivators, share-croppers, day-labourers, school
rural extension workers’ encouragement and ^teachers, women, and others including traditraining to maximize the use of the local resour , tional leaders. In some cases, however, a few
members of the VDC may be nominated by SCF/
ces—its people and its land.
CDF. The task of the Committee is to: a) assess J
Objectives of SCF/CDF are the following:
their own needs, b) prioritize their needs, c) plan
i) To help the target population create effec projects, d) implement the projects, and e) to -■
tive grassroots infrastructure and proces evaluate these projects.
ses of decision-making for the articulation
These tasks are carried out with the assistance
of activities to meet their priority needs;
of the SCF/CDF extension worker (Field Coordi
nator).
The Committee is a liaison between SCF/
‘Program Officer, Save the Children Federation/Com
CDF and the village. This Committee also evalumunity Development Foundation, Dacca, Bangladesh.
December 1977
21
ates the utility of projects, selects projects on the
basis of priority and mobilizes the village people to
participate in the work needed to get a project
completed. The projects are of different kinds. We
encourage income generating projects such as
Agricultural Project, Pisciculture, Sericulture,
Handicrafts like Tabla making (musical instru
ment), Biri (Cigarette) making, Pottery, etc. to
develop individual and community income. In
addition to these villages also carry out social in
frastructure projects such as health clinics, road
construction, school maintenance, family plann
ing, nutrition, health, etc. Project expenses are
generally shared by villagers and SCF/CDF.
Costs of materials are generally borne by SCF/
CDF, with the villagers contributing a share. In
direct expenses such as land or labour are always
contributed by the village folk. We gradually de
crease the SCF/CDF share and the villagers in
turn assume the responsibility of paying total costs
for social infra-structure projects with a portion
of the profit from income generating projects.
setting priorities for project planning in solving
their own problems to develop their life situa
tion; b) how projects for income generation can
support social service projects through the crea
tion of a village fund; c> how inputs and outputs
can be casted to determine whether or not a vill
age project will be really benficial; d) how vill
age goals can be derived by understanding vill
age condition; and e) how projects succeeded in
village and could be tried in another. These ma
terials were all developed and field-tested in the
project villages and are all accompanied by in
struction for their use. We have used our this
visual planning kit in all of our project areas and
it had great impact in presenting our philosophy
of rural development.
Experiences in Jabra
Jabra is a village under the Ghior Thana in
Manikganj Sub-Division of Dacca District. The
village is adjacent to the Dacca-Aricha highway
and is about 40 miles from Dacca. It is an ordi
nary village with its share of poverty, food defi
cit,
lack of employment facilities and the many
One example of this is that the expenses of the
Health Nutrition and Family Planning Program other signs of economic backwardness which are
characteristic
of the villages of our country.
me in one of our project villages is borne by the
Village Development Committee. In this way at Population of the village is 4,400. The approxi
mate
average
annual income per family is Tk.
some point SCF will not remain in that village
and the VDC will be self-sustaining to run their 3600/-. 60 per cent of the people are farmers of
whom
40
per
cent
are landless. There are both
programme by their own created funds. The
CBIRD programme is designed to demonstrate Muslims and Hindus in the village but mostly
the
people
are Muslim. There are two sections
the concepts and processes of: a) involving com
munity people in planning, b) identifying pro of a Hindu community and they were suppressed
blems and opportunity in villages, c) assessing by all others. But their artisanship in leather
needs and priorities, d) mobilizing local resour work and pottery has a good potential to raise
their economic status and create employment
ces, and e) pooling external inputs and assistance
for implementation of different activities in order opportunities in the community.
to establish a community in continuing develop
The main agricultural crops are paddy, jute,
ment for self-reliance.
and tobacco. Of 360 acres of cultivable land,
only 180 acres were irrigated. One fulltime SCF
Local training staff provide regular guidance representative is posted there as field coordinator
and stimulation through training to the villagers. who also stays in this village. During October
Development of community spirit, leadership and 1975 SCF/CDF started programme in Jabra vil
equality in leadership, and skills for develop lage. Initially they started -with a test project,
ment are the centre of the assistance given to (roads and embankments) which proved success
villages. We have developed a set of very simple ful and ultimately then CDF started working in
visual materials—"Village Planning” and "Needs full swing.
Assessment” kits in order to help villagers; a)
participate in discussing problems in their com
The Jabra VDC which is formed with the cross
munity, determining the major problems and in section of people is participative, sincere and in
22
Voluntary Action
terested and committed in developing their life
situation through the CBIRD programme. The
able and efficient field coordinator of SCF/CDF
who has two years practical field experience in
rural development, worked with the Jabra VDC
to guide and assist them.
The most distinguishable achievement among
the projects is the "Leather Project’’ for lower
caste Hindus. This project has changed their
fortunes. There are about twenty-five families
involved in this project. They were poorest o£
the people working as cobblers and sometimes
playing musical instruments was the only source
of their income. Socially these people were outcastes and such was their plight that other peo
ple 'even refused to talk to them. Nov/ under
the project they have been taught and encourag
ed to make bags, drums, and tablas. SCF/CDF
has been providing the necessary finance, and
returns from the sale of the goods enabled them
to develop their life and to stand on their own
feet.
the rickshaw pay Tk. 5/- daily from their income
of the village fund as a repayment of the price
of the rickshaws. They are earning Tk. 12/- to
Tk. 18/- per day in average which ensures a
better life than previously.
There is one youth furniture project. Furni
ture is given on a rental basis to people on occa
sions such as marriage and other ceremonies and
provides source of income for the youth group.
They can use this income in purchasing their
materials and may spend for recreational activi
ties.
The VDC also started a sericulture project
for producing raw silk in collaboration with the
Canadian University Services Overseas (CUSO).
They helped the VDC to train one lady of this
village from Rajshahi and this lady is giving
training to few other ladies on the job. This is
expanding very quickly and seems very impres
sive. Primarily landless families will receive
benefit from this project. ,
Another project which has been planned this
The other achievement of VDC is the Bidi fac
year is the cattle raising project for the destitute
tory (cigarette). The land and buildings for the
women and landless families. A total of twenty
factory have been contributed by a village family.
families, each will receive a milk cow and they
The cash capital for the project has been pro
will return the cost of the cow in instalments and
vided by SCF/CDF. The number of workers in
give a part of their income to the VDC fund for
this factory are 43 mostly women of very poor
class and many were beggars. The VDC with general community welfare.
the guidance of SCF field coordinator organized
There are some social service projects. The
and motivated them to work under this factory. population problem has been noted as the num
They come to the factory at certain time and take ber one problem of the country and as a develop
raw materials to their homes, then they work, ment organisation we also have an integrated
filling in the Bidi papers with tobacco. There .family planning programme, Family Planning
is a paid manager to supervise the worker and Through Village Leadership. The VDC planned
to make arrangement for marketing the products. this as Health, Nutrition, and Family Planning
In the initial stage the workers are getting project. The rate of acceptance through our ap
Tk. 4/- per one thousand Bidi. One efficient proach is also impressive. The rate of current
worker can fill up 4-5 thousand Bidi with tobacco users is 24 per cent among the eligible couples.
in a day. Though it seems that this is very low And total 38 persons have been sterilized during
—still they have a chance to earn which previous this year. The sewing project is intended for
ly they could not. We hope that after certain. women so that they not only learn sewing, but
period they will be able to earn more—when also meet each other and come into clearer social
there will be enough facility for marketing.
contact. Besides these construction of earthen
village roads, culverts, school maintenance, com
In another project the VDC has purchased five munity centre, etc. are included here. These
rickshaws and given them to five landless labour show a broad range of successful projects.
ers. These labourers were generally unemployed
or underemployed. The persons who received
As we are carrying out an experiment in estab
December 1977
23
lishing a model for rural development, not all are
stories of success. Similarly we have failures
also. In Jabra village, the VDC tried vegetable
gardening with a youth group . Dacca office staff
arranged for seeds of different kinds of vege
tables and they tried to establish a model kitchen
garden in the village. The project failed. The
reason for their failure was lack of knowledge
as it was not the proper time to grow these
vegetables.
To increase the rate of adult literacy in the
village, the VDC tried to establish a functional
literacy programme. Classes began, but most
dropped out quickly as we found that the adult
students are working throughout the day to
maintain their family and at the end of the day
they are tired, just as the class of functional
literacy is to start.
The VDC undertook an irrigation project fc
farming to increase the food production. But the
result was less than 20 per cent of the expected
yield, due to low understanding of HYV rice
techniques. A similar project was undertaken
in one of our villages, in Rangunia thana under
Chittagong District and that was a successful pro
ject in recognition of which the village received
government award. Their project had received
good agricultural advice.
The CDF staff have reviewed the problems of
the project in Jabra in detail and have assisted
them in the preparation of a second year plan.
The reasons of the failure of Jabra irrigation
project are—the seeds were planted late, seed
beds were prepared incorrectly, fertilizer applied
too late or too early, and pumps rented from
BADC broke down at a critical point. CDF didn’t
have any agriculture expert also. But recently
we have hired an agriculturist who is a graduate
from Agricultural University and has three years
field experience.
The non-formal visual training materials we
have developed in the SCF/CDF office in Dacca
began in Jabra village. At our take-off stage we
started to design and test the materials with the,
efficient field coordinator of this village who is
experienced in materials development. Then we
also tested some materials in Rashiddeohata vil
24
lage of Mirapur under Tangail District. After
field testing we finally prepared the visual
materials and user’s manual for the same.
It is a continuous process of field test
ing, use and modification which takes place con
tinuously. We arranged' training for the Jabra
VDC with our Needs Assessment Kit, and Village
Planner Kit which helped the VDC to understand
their village problems, discover the major pro
blems and plan projects in a better way. The
VDC is very interested in this visual system of
training and villagers were clearly enthusiastic.
Some lessons from our experiment are :
(a) Community leaders are able to assume day
to day management and supervision of
the programme if they are trained.
(b) Leaders are willing and able to assume
responsibilities.
(c) Intensive meetings with local workers
coupled with assistance from resource
persons can help the village to be selfreliant and to have a better environment
in the community.
(d) Sequential visual training materials accom
plish at least two major objectives:
(i) Provide non-literates the opportunity
to effectively plan income-generating
projects, and
(ii) Greatly broaden participation in pro
ject choice and planning.
Very recently we have developed our nonformal approaches for training (during February
1977 onward). We are still modifying the mate
rials through using in the villages. We used the
non-formal approach during our recent project
planning session. In all our villages we used the
'Needs Assessment’ kit and accordingly all pro
jects were planned. It is helping the people in
open and easy communication among themselves,
increased the participation of all sects of people
in discussion. We cannot show any clear evidence
regarding the impact of the approach on pro
gramme now but it appears to use that this ap
proach will be very much useful to the illiterate
poorest of the poor to participate in discussions,
understand their problems and means of over
coming the problems.
Voluntary Action
Vol. I No. 1
May/June 1981.
Newsletter of the Asian Community Health Action Network.
Editorial
Feature
ACHAN: A Brief History
This is the first issue of LINK, the
ACHAN newsletter. With its publica
tion we initiate a formal communication
j n the past decades a growing cally co-ordinate an exchange of infor
link with our membership. The prelimi1 number of people have become mation, personnel and training experi
nary format of the newsletter will inclu
committed to and engaged in ence among these groups, secular
de an editorial, a feature article on iss exploring ways by which helath of large and religious, on a sustaining basis:
ues of community health, a review of numbers of people can be improved
The idea for a formation of an
ACHAN’s activities and plans, a report rapidly. Under the' umbrella of ’’com
’ Asian community health network
on the programme of one of our mem munity health” several groups and
began two years ago among mem
bers, a ’’Co-ordinator’s Corner” repor individuals have created alternatives to
ting the co-ordinator’s activities and traditional systems of health care bers of an ad hoc planning committee,
a review of publications of interest delivery which are plagued with the (see Appendix 1) all of whom had
to our membership with information problems of limited resources availabili experience in community health work
about how to receive these publications. ty. They have been able to do so,in part at the local and/or international level.
ACHAN was created to respond to the because 1) they have analyzed health Members of the Committee had made
needs of its members and LINK is an in terms of its social, political and the following observation about com
arm of ACHAN. In otherwords, the economic implications, 2) they have munity health work in its present stage
newsletter is designed to provide infor viewed community health as the active of growth: Firstly, the term community
mation which its membership finds participation of the community in health could cover a range of program
useful. It is designed to respond to and health care, not as merely the extension mes from the mere extension of me
reflect your wishes. For this reason, the of medical services to the community dical services to the community to
active
involvement
of
format is flexible. If you feel certain and 3) they have considered health the
articles are not useful or if you want as an integral and crucial part of natio people in their own health care. As the
information about areas we do not nal development programmes. The more majority of people in most countries
cover at present PLEASE LET US innovative programmes often have still used the first definition, people
KNOW. In addition, we want to LINK grown out of the voluntary agency committed to the participation of
various community health individuals sector. They have influenced policies the community in their work found
and programmes with each other. We and programmes of both the national great comfort and support in continu
can do this if you provide information governments and the international agen ing contacts with others who shared
about your programmes, your views, cies such as the World Health Organi their views. Secondly, people in this
latter group found it stimulating,
your experiences. Again, PLEASE zation and UNICEF.
helpful and even necessary to partici
WRITE TO US. LINK is your news
Many of these innovative program pate in conferences and workshops
letter. It will be of use if you give your
contributions. We look forward to hea mes have developed in Asia. Program with others in the region doing similar
mes like Jamked in India, Solo in Indo work. However, they became disap
ring from you very soon.O
nesia and Sarvodaya Shramadana in Sri pointed in and skeptical of the purpose
Susan B. Rifkin Lanka have attracted international in of these gatherings when these meetings
ACHAN Co-ordinator terest. Community health programmes produced no follow-up work or ways of
which share the orientation of inte continued contacts and exchanges.
grating health, development and partici Thirdly, efforts for exchange of informa
pation have a number of experiences tion, materials and personnel depended
which can benefit everyone who on chance rather than systematic coordi
is engaged in this work. Yet, to date nation. If people knew about the activi
there has been no attempt to systemati- ties or developments in another prog-
ramme at the national and/or regional the consultation and to recommend to help initiate, support and sustain
level, it was most often only that by either its continuation or demise. The community health work among non
chance they met a person associated mandate called for a small office with a governmental organization in Asia by:
with or had information about that pro co-ordinator and a secretary to adminis
gramme. Thus, in programmes with ter ACHAN activities. It was proposed 1. providing documentation of Asian
experiences in community health
already scare resources, unnecessary and accepted that the office in the first
done by Asian themselves (this
waste and duplication occured due to instance be located in Hong Kong
documentation includes research,
the lack of knowledge about expe where both the Chairman of ACHAN
analysis, scientific evaluation, study
riences of other groups dealing with and the coordinator live. The consulta
and reflection on various commu
similar problems and/or developing si tion suggested that ACHAN begin to
nity health programmes in Asia);
milar activities.
function officially on January 1, 1981.
In preparation for its work, however, 2. establishing communication and ex
In an effort to discuss and reflect
change of information among its
upon these observations with people tire executive committee of the Board
members through newsletter, ex
who had a diversity of experiences accepted an invitation to travel to Japan
change of materials and visitations;
and lived in different. Asian countries to advise and consult the Asian Health
but who shared committment to com Institute which is in the process of esta 3. assisting members when requested to
munity health in which members of blishing a training programme for rural
develop training techniques and
community health workers in Asia.
programmes;
the community actively participated,
during October, November, December,
4. assisting the development of national
1979, various members of the ad hoc
community health networks where
OBJECTIVES
planning committee visited people thro
they do not exist;
ughout the region. These people,
ACHAN is an explicitedly secular 5. facilitating the exchange of pro
representatives from a wide range of
organization
and
is
a
functional
rather
gramme
personnel;
national, cultural and religious back
than structural group which has two
ground validated the observations of
6. in the long term, developing a data
basic objectives.
the committee and, for the most part,
bank of people, programmes and
gave support to the idea of the creation
technologies as a catalogue of re
The first is to propagate, popula
sources.’
of an Asian community health network.. rize and pursue a philosophy of com
As a first step, plans for a small explora munity health which:
tory meeting were drawn up.
1. sees health as the physical, mental, PLAN OF ACTION
social and spiritual wholeness of the
The ad hoc planning committee
In pursuing these objectives while,
individual and the community not
* met in December, 1978 gratefully
the mere delivery of a medical ser at tire same time, remaining a facili
accepted Dr. Ding’s (Chinese Me
tating network rather than a bureaucra
vice;
dical Research Centre) offer of sponsor
tic organization, ACHAN seeks to ex
ship and reviewed discussions that had 2. gives priority to the deprived mempand its membership to include those
bers of any community;
been held with a wide range of people
who accept its philosophy of commu
involved in community health in Asia. 3. makes health understandable and nity health and wish to be involved
After considering the interests of vari
accessible to all, using tools such as in the described exchanges. Member-1
ous people with whom the7 ad hoc
auxiliary care, indigenous remedies, ship of ACHAN is developed in three
planning committee had met and the
appropriate technology, concepts of catagories. The first is members of
community development, and invol the Board of Directors which compose
various groups which these people
represented, it was decided to invite
vement of the community in plan the managing body of ACHAN’s ac
a group of about 15 people to join
ning, implementing and evaluating tivities. The second is ordinary members
the planning committee for a meeting
health care programmes;
consisting of programmes, individuals
in Bangkok June 21—24, 1980. The 4. stresses comprehensive approaches and national organizations who sub
committee applied for and was granted
scribe
to ACHAN’s philosophy of
for improving the total health of
a sum of money to convene this meeting
community health as described above
the community;
by EZE (Protestant ■ Central Agency
and live in Asia. The third is Friends
for Development Aid, West Germany). 5. helps the community to become of ACHAN who subscribe to the philo
aware of the broad range of develop sophy and live outside Asia. All mem
ment problems through health work; bers pay a membership fee.
The Bangkok meeting created
and
the Asian Community Health Action
0)
Network (ACHAN) and mandated it 6. views health problems and priori ACHAN is governed by a Board of
with a three year life span. At tire
ties in the terms in which the com Directors working through an executive
munity sees them.
end of this period, the consultation
committee. The Board of Directors con
The second objective is to facilitate sists of one person from each country
agreed that members present would
review the network to see if it had fulfil the exchange of infomation, materials represented at the Bangkok Consulta
led the objectives and expectations of and personnel among its members and tion in June, 1980. The executive com-
2
mittee consists of six people including member programmes and other agen
the Chairman of the Board, the Hono cies. Other activities also will focus
rary Secretary, Honorary Treasurer, on promoting, assisting and maintaining
the Co-ordinator and two other ap the philosophy of community health Programme: Gonoshasthaya Kendra
pointed members. A list of the execu articulated in the objectives.
(People’s Health Centre)
tive committee, the Board and the pre
Director
: Dr. A.Q. Chowdhury
sent membership can be found in Ap APPENDIX I
Address
: P.O. Nayarhat via Dhapendix 2. The Bangkok Consultation
Members of the Ad Hoc Planning
mari
mandated the network to function be
Group for an Asian Health Action Con
• District Dacca,
ginning January 1,1981. A co-ordinator
sultation.
BANGLADESH.
with a 3-year term of office has been
appointed. An office is located in 1. Dr. L.K. Ding, Chairman
Program Report
Hong Kong.
2. Dr. Prem John
Short Description of the Pro
gramme:
3. Mr. Samuel Isaac
ACHAN’s activities are geared to
Gonoshasthaya Kendra is a rural com
reflect the facilitating nature of the 4. Dr. Hari John
munity health and development pro
network. As mentioned above, a first 5. Ms. Susan Rifkin
gramme. The health programme is de
activity was to send, at the request
signed to operate primarily with para
APPENDIX 2
of the Asian Health Institute, five
medics providing preventive care in the
members of the executive committee BOARD OF DIRECTORS OF THE village. This includes health/nutrition
jto consult on training programmes ASIAN COMMUNITY HEALTH AC and sanitation education, immuniza
of the Institute for community health TION NETWORK (ACHAN):
tion (BCG, DPT & Tetanus), family
workers in Asia. Other activities will Executive Committee Members :
planning (with necessary follow-up),
build upon the requests and needs of
and observation of pregnant mothers
Dr. L.K. Ding, Chairman
the expanded ACHAN membership.
for what could be complications.
Hong Kong
In order to define concretely such
There are four sub-Centres which
actions, the first step will be to iden
serve as a working base with facility
Dr. Qasem Chowdhury
tify prospective ACHAN members, re
for simple pathology, minor surgery
Bangladesh
cord information about their program
(including tubal ligation) and doctor
Dr. Lukas Hendrata
mes and/or interests and analyze their
referral service one day per week.
Indonesia
potential needs and contributions to
There is a back-up main Centre with
the development of community health.
a 15 bed ward and pathology, X-ray
Dr. Prem John
To collect this information, a brochure
and operating facilities.
India
about ACHAN’s operations will be
Apart from providing training of its
Dr. Kim II Soon
printed with a simple ACHAN addressed
own staff in paramedic work, patholo
Korea
return: form to be completed with pro
gy, X-ray, operating theatre (most
gramme operations, needs and contri Members :
sterilization is carried out by parame
butions described. It is forseen this
Dr. Abhay Bang
dics) and ward duty, training program
..exercise will occupy the first months
India
mes are available for other Govern
4 ACHAN’s official existance.
ment and non-Govemment groups in
Dr. Manolet Dayrit
On the basis of this data, through
community health work, from illite
Philippines
rate grass-roots level through post
a continuing dialogue with ACHAN
graduate,level workers.
members and with the specific recom
Dr. Hirorni Kawahara
mendations of the ACHAN executive
Japan
The main emphasis of the entire pro
committee which is scheduled to
Dr. H. Kusnadi
gramme is on women and their parti
meet every six months, specific activi
Indonesia
cipation/ involvement in various activi
ties will be developed that will help
ties which we see as essential if there is
the membership to develop their parti
Dr. Park Kyong Wha
to be a change wrought in the socio
cular needs. It is already forseen that
Korea
economic structure which now exist.
one such activity will be a regular
We
try to recruit workers from the
newsletter containing relevant informa
Dr. Sant Hathirat
lower levels in the class structure and
tion about programmes, technologies
Thailand
by giving them appropriate training
and other defined interests. Another
Dr. V.L. de Silva
and responsibility help them prove to
will be to help develop training pro
Sri Lanka
themselves (and others) that they
grammes for community health trainers
are capable of many things which pre
in the region. It also is forseen that Co-ordinator :
sent society considers outside their
channels will be developed whereby
Susan B. Rifkin
’traditional’ role (child bearing and do
ACHAN members will be available
Hong Kong
mestic ’servant’).
for consultation upon request by
3
village-based (remain in the village Finances:
Gonoshasthaya Kendra began as a working out of their own homes and Gonoshasthaya Kendra is a non-Govemfield hospital during the Liberation reporting in to the main or sub-Centres ment organization. The health insurance
War in 1971, using village youths periodically), 20 work out of the sub scheme finances about 45% of the
to cany out simple medical procedures. Centres and the remaining 12 either health programme with contributions
Tire Organizers, after the war, realized work out of, or in (ward, pathology, from NOVIB of Holland and OXFAM,
the need for village-based health pro X-ray, operating room), the main England contributing the rest. The
gramme and began training young Centre. 15 trainee paramedics are pre training programme receive assistance
villagers (mostly girls) to carry out para sently doing their field work under from Inter Pares of Canada.
medic work. As a result of their work the direct supervision of senior para
Ways of achieving self-sufficiency:
among the villagers, these young prople medics.
realized that more than a health pro Another 15 persons are involved in
Complete self-sufficiency will probably
gramme was needed for the develop administrative/clerical work.
only come when the poor finally con
ment of the entire village system and Area of operation:
trol enough land and water resources
gradually various other programmes
Savar Thana (an administrative unit) to keep themselves healthy. Our task is
have been added.
with a service population of approxi to help provide the education and moti
Social Context in which Pro mately 100,000 is the base of operation. vation which may help bring this to
gramme operates:
This is mainly farming and fishing a reality.
The workers themselves live and work communities, located about 23 miles
Evaluation methodologies:
,f
(in the main and sub-Centres) in a from the capital city of Dacca.
system based on the concept of total Target Groups:
Each department head submits a month
community participation and this is
ly, report on all aspects of the pro
carried over into their work which is Our priority group is the landless and gramme family planning, births &
done entirely in the rural villages of marginal farmers and poor fishermen deaths, immunization, infectious di
in the area who must have health care
Bangladesh.
seases, night blindness, pregnant mo
provided in the village as they cannot
thers, etc. These are presented at a re
Objectives:
afford (monetarily or time-wise) to go
gular meeting of all health staff. There
to
clinics
or
hospitals
for
this
service.
To provide preventive health care to
is also discussion on whatever problems
the villagers within the Project area,
they may be encountering in their work.
Training :
but more importantly, to train the
villagers themselves to the realization Paramedic training is conducted through Relationship with Government
classes
in
anatomy
and
physiology
that good health is their responsibility
agencies:
and help them find means to make this- treatment of simple diseases encounter Our working relationship with Govern
a reality, given their socio-economic ed in the village, vaccine/immunization ment agencies is good and as previously
procedures and recording, family plan
situation.
ning and follow-up methods, ante-natal mentioned, a number of their commu
Structure of the Programme:
care, etc. Trainees usually go to the vil nity health training programmes are
The Project Director has overall res lages with a senior paramedic during the conducted at Gonoshasthaya Kendra.
ponsibility for the training and imple day with the above-mentioned classes be There is also interaction in planning.
and presentation of various seminars"
mentation of work, but this is not ing held in the evening. Included in the
done in an isolated manner. Senior evening sessions is discussion on various workshops, etc.
Short History of the Programme:
paramedics are in charge of all the
sub-Centres and their works and needs
of departments responsible for the
work in their sectors. An effort is
made to make all aware of their parti
cular responsibility in the programme
if the overall effect is to be satisfactory.
problems/situations encountered during
that days work in the village. Training
is usually 6—12 months, depending on
the progress of the trainee. Refresher
courses on various topics are available
for seniour staff members.
Significance of the Programme
in relationship to government:
92% of the people of Bangladesh
live in rural areas and 70-80% of these
below subsistence level. Since our
programme is village-based and directed
Other
training
programmes
are
depen
at this target group, it is in direct
Personnel in the Programme:
dent on the requirements of the various accord with services Government is
There are 3 doctors for overall parti requesting body, e.g. UNICEF, IRDP,
attempting to provide. However, this
cipation in/supervision of, the various
Medical College, Post-Graduate, etc., does not mean our views on basic
training programmes, both, theoretical but in all of these, the emphasis is
problems and the means to solve these
and practical. They also serve as the
on getting the student into the village are always in agreement with Govern
back-up referral at the main and sub
where community health is (or more ment and we make use of various
Centres and are responsible for those
accurately, isn’t), rather than sitting Government organized seminars, etc.
aspects of professional care for which
in a classroom discussing how it should to present healthy arguments with
paramedics are not equipped.
be done according to the Western the hope of reconsideration and change
Of the 43 trained paramedics, 11 are textbook.
of policy on some issues.
Achievements :
(unpaid by the Centre) in his own
village and our paramedics would be
The health programme has a 60 - 70%
available in a supervisory capacity. We
coverage of BCG, DPT & Tetanus
also hope to start 2 more Centres.
immunization in the service area. As
a result of family planning and follow Things possible for programme Although ACHAN only began to func
up activities, it has one of the lowest to share:
tion officially Januari 1, 1981, the exe
birth rates in the country. Because of
cutive committee accepted the invita
the intensive supervision of pregnant The success and failures of 9 years’ tion of ACHAN member, the Asian
mothers, there were no deaths from experience and some of the reasons Health Institute in Japan, to talk with
eclampsia in our insurred area during for these.
AHI staff about their training pro
the past year. There is a decrease in
gramme for Asian community health
the death rate from diarrhoea resulting A training programme which seems workers. The first training group was in
from the training of mothers to treat to equip the worker to deal adequately residence in Nagoya when the consul
it early with sugar-molasses (however, with the normal, simple health pro tation took place allowing for some in
due to lack of clean water, there is blems encountered in village life.
depth conversations with participatns
no decrease in the incidence of diar
in the programme. The consultation
rhoea).
proved mutually beneficial to both
Needs of programme:
ACHAN and AHI. It gave all of us a
Dedicated people, able to understand chance to express and explore ideas
Shortcomings :
village life and willing to work in a about courses, objectives and methodo
k)ur health programme has not been
village situation.
logies in training programme which
able to reach as much of our ’’target”
group as fast as we would like it to due Ways and means of becoming more self- would be relevant to the needs of rural
Asia. One proposal was to establish a
to the powerful socio-political-economic sufficient.
series of training modules from which
control of the elite. This keeps us
trainees might chose the subjects most
searching for and trying, to promote Other Comments :
relevant to their own work. These mo
some type of programme which can put
dules might include oriental medicine,
As
mentioned
previously
,
due
to
various
at the disposal of these poor people,
basic medical treatment, community de
situations
being
constantly
met
in
our
the means to better their socioecono
velopment skills, community health
mic condition and thus improve their village health programme, it become
evident that there were other needs worker training, etc. We recently
health situation.
which also had to be met — health received tenative plans for the next
As the Project has grown and additional could not be done in isolation from AHI course. When the plans are fina
staff has been needed, some have come the realities of daily living. For this lized we shall give details in LINK. The
without the idealism which the ’’found reason the programme expanded into executive committee of ACHAN met in
ing” members had. Also, there are a development programme. There is a Indonesia, March 24-29, 1981 to re
people in the country who do not large vocational training programme view ACHAN’s early activities and plan
wish to see a programme such as this (with emphasis on women’s training) for the future. It was decided that a
succeed. A combination of these ele- including jute handicrafts, shoe factory, major effort for the next two months
Iprents led to a ’strike’ early in 1980 metal workshop, carpentry and a ba would be to publicize the creation of
which made it imperative for each kery.
ACHAN and to expand the member
member of the organization to take
ship. Brochures are being printed and
a good look at himself/herself, why A school was started for the children letters written to help in this effort.
they were here and who do they really of the landless and marginal farmers Membership forms are attached to this
wish to serve - a painful, but hopefully who would otherwise have no opportu newsletter. Please distribute them to
growth-filled experince. A programme nity of education. To help the farmers other potential members.
such as this has to be a challenge which break their dependency on the land
all accept for the good of all we aim owners and moneylenders, our agricul Another area in which ACHAN is be
ture loans programme began (and ginning to take a serious interest is that
to serve.
seems to be succeeding well). A publi of developing programmes to help train
cations
department was added for the trainers of community health workers.
Plans for the future:
purpose of providing relevant health It is hoped that within the next year
Success with the villagers themselves information to village doctors and ACHAN in co-operation with other
taking responsibility for the running the villagers themselves in the local groups interested in this area will be
of the agriculture loan co-operatives language and also for developing teach able to create a training course to help
has led us to hope that in the near ing aids for our school and adult (vil those working in community-based
future they will also be able to take lage) literacy/education programme. health programmes to exchange expe
on responsibility for their own basic The most recent venture is a pharmaceu riences, materials and skills and to help
health care. We would like to train tical factory for the exclusive manufac- those who wish to initiate these typfe
one of the villagers to do this work: ture of generic name drug? at low cost. of programmes.
ACHAN Plans
and Programs
5
ACHAN executive members also dis
cussed the possibility of ACHAN pro
viding consultancy services to people
in community health programmes.
------ 7’
Giving priority to programmes who are
just in the beginning stages. ACHAN
will provide exchange and advice upon
request. Fees will probably be charged
--------- 7------ ----------------------------- ------------- ----------------
for this service as another means of
making ACHAN self-supporting. Con
sultancy activities need to be examined
in greater detail at future meetings.
...---- ---------------------- -—----------------------------------- —--------------
Co-ordinator’s Corner
Although only officially in existence I then left Prem and travelled to the ing to establish office routines, han dl in g.
for less than six months, ACHAN has Third International Congress of Public membership applications, etc. In June,
received a rather enthusiastic response Health. Associations meetings in Cal Prem and I travel to Sri Lanka to meet
and support for its objectives and ac cutta. Here 1 was able to discuss the ACHAN members, Lashman de Silva
tivities. In addition to die one-quarter creation of ACHAN with members of and Joel Fernando, and to visit others
financial support contributed by its core Asian Public Health Association, WHO, who have expressed interest in
membeship, ACHAN has now received UNICEF and several European friends, ACHAN’swork.
other large financial contributions to ; It was a good opportunity to exchange
support its administration from the views and to learn about developments One of our members, the International
Canadian International Development and concern in the area of Primary Hospital Federation, with whom we
Agency, Appropriate Technology inter- Health Care and community based have reciprocal membership, is offering
nation al (USA) and EZE (Germany). health programmes.
a number of study tours in 1981. These
For this assistance we are very grateful.
touts are listed below: 3
In order to discuss ACHAN and to dis I now sit in Hong Kong until June workcover the needs and interests of mem
10-17 May
Hospitals and Primary Health Care (PHC) in the
bers and potential members, I travelled
(now fully booked)
German Democratic Republic
to India in February. In Delhi, Prem
John joined me and we had discussions
31 May - 12 June
Child Health Services in Canada
with the Voluntary Health Association
of India (VHAI). We also met with Dr.
20 - 29 July
First-Line Hospitals and PHC in MexicoJ
Daleep Mukarji, of the Rural Unit of
Health and Social Affairs (RUSHA),
8- 18 September
Fire Safety in Hospitals and Homes for Elderly and:
Vellore, who told us of their plans to
Disabled People
introduce a community health mana
gemen t course for graduates: in their
project area. ACHAN has been asked If you are interested, as an ACHAN subject, any ideas : about how; such
to co-sponsor a workshop for curricu member, you are eligible to join. For seminars might be executed, any contrilum course planning in November. We ■ further information write us at tlre co butions you or anyone you know could
shall provide details in a future issue ordinating office: ACHAN, Flat 2A, make and any other comments you
144 Prince Edward Road, Hong Kong might have. We would very much appre
of Link.
or to : Mr. Miles Hardie, International ciate your help and reactions to this
While in Delhi, Prem and I visited WHO Hospital Federation, 126 Albert Street, idea. ::
regional headquarter and spent a short London NW1 7NX, ENGLAND.
time with Dr. Mutalik, Director of De
Finally, a personal request. We would
velopment of Comprehensive Health Another member, AHI (Asian Health very much like to hear from you, So
Services. He was very interested to ; Institute) is exploring the possibility please write to us with your questions,
know about ACHAN and told Prem to of holding seminars on herbal medi comments and ideas. In this way
keep in touch with him about deve cines in Asia, Could you please send to ACHAN can serve you.D
lopments.
us any infonnation you have on this
6
Through its circulation of over 14,000, tal, in the field of international health
it provides a range of world wide ex- care and development policy.
- periences which focus on the importan
ce of the human factor in health care. Salubritas
In this first issue of LINK we are re Contact also reviews meetings, publica
viewing some of the publications tions activities in the area of community Address :
American Public Health Association,
which appear regularly in the form of health.
1015 Fifteenth Street, N.W.,
journal or newsletters and have inter
Diarrhoea Dialogue
Washington,
DC 20005, USA.
national, mainly Third World, coverage.
They all can be obtained free; that is Address :
Salubritas is a quarterly publication
AHRTAG,
85
Marylebone
High
without any payment. To receive
in English and Spanish sponsored by the
Street, London, W1M 3DE,
any of these publication, simply write
American Public Health Association and
ENGLAND.
to the address provided and ask to be
the World Federation of Public Health
put on their mailing list.
This is a quarterly newsleter published Associations. It is funded by the United
Comparative Health Systems Newsletter
States
Agency for International Deve
by the Appropriate Health Recources
Address :
and Technologies Acting Group in lopment. It contains feature articles on
proramme
experiences on both the na
Departement of Community Medi London. Concentrating on the problem
cine, University of Connecticut of child care for diarrhoeal diseases, tional and local private agency level, use
of
appropriate
health technologies, and
Health Center, Farmington,
it uses this problem as a launching point
discussion on disease control and other
k Connecticut 06032
to explore areas such as use of appro
public
health
problems.
In addition, it
'’This newsletter is sponsored by the priate technology, health education,
Northeast Program for the Cross-Natio health auxiliary training programmes publishes notes about activities of pu
blic
health
conferences
and
health train
nal Study of Health Systems, and is sup and other policies and potentials in the
ported in party by a grant from the U.S. field of maternal and child care. It re ing courses and a list of health and
health-related
publications.
World-wide
Dept, of Education to Harvard U and ports news about MCH programmes,
the U of Connecticut” (quoted from types of treatments, approaches to in coverage and concentrating on deve
lopments
in
the
less
developed
coun
Comparative Health Systems Newsletter health problem solving and feature
vol. 2, no. 2, December, 1980). Orien articles on broad policy issues. It also tries, this newsletter is designed to
ted to the academic, this newsletter contains a section on practical advise exchange experiences and ideas of and
presents views about issues of health and one on questions and answers about for public health practitioners who
care, reports on recent meetings, sum treatment and prevention of diarrhoea need practical information about how
maries of up coming meetings, and in and other health-related problems. Ar to confront broad health problems.
formation about people engaged in the ticles are written by noted authorities World Health Forum
research of comparative health systems. in the field of primary health care and
Address:
It also provides information about MCH work. Oriented to people working
Dr. A. Manuila, Director,
organizations working in this area. It in the rural areas of the less developed
Health and Biomedical Infor
has a rather extensive review of recent countries, the journal focuses on prac
mation Programme,
publications which summarizes selected tical information relating to MCH care.
World Health Organization,
|aooks and theses on the subject of
1211 Geneva 27,
comparative health systems. It provides Newsletter (of the National Council for
SWITZERLAND.
a fairly comprehensive view about work International Health)
World Health Forum, and international
and activities in this research field.
Journal of health development, is a new
Address :
Contact
National Council for International quarterly intended for health planners
Address :
Health, 2121 Virginia ave. NW Suite and administrators, teaching staff in
Christian Medical Commission, World
303, Washington, DC 20037, USA. schools of public health and similar
Council of Churches, 150 Route de
institutions, and anyone else interes
This newsletter reports the activities of
Ferny, Geneva 1211
ted in primary health care.
the National Council for International
SWITZERLAND.
Contact is published six times a year in Health in the United States and news, Meant to be a forum for ideas, the
four languages: English, French, Spanish such as US governmental international editors hope readers will submit arti
and Portuguese. It presents descriptions, health policy, which affects the func cles, letters, essays and book reviews
of innovative community health pro tioning of tire council. It reviews health for publication. The first issue (Vol. 1,
grammes in the developing world dis publications which can be ordered from Nos. 1 and 2, a trial issue) carries arti
cussions about various community the Council, announces Council spon cles on mental health awareness in
health issues such as healing and whole sored meetings and reports activities Honduras, drug costs in Sri Lanka, and
ness and use of traditional medicine of Council members. It is an informa an essay entitled ’’The malaria pro
and reports of various CMC meetings. tion sheet which familiarizes readers gramme - from euphoria to anarchy.”
To date over 50 issues have been pu with the activities and concerns of US World Health Forum is published in
blished over the past five-six years. agencies, both private and governmen English and French.
Publications
Note:
Application For ACHAN Membership
Do you want to join ACHAN?
or in local currency, where possible to
the Board member of your country
Members of ACHAN are those who
subscribe to the ACHAN philosophy whose address is listed below:
of community health, and pay member
Bangladesh :
ship fees.
Dr. Qasem Chowdhury,
As ACHAN is working toward self- Gonosasthaya Kendra,
sufficiency, we are asking for the mem Nayarhat via Dharmari,
bership fees listed below. This amount Dacca.
is a minimum contribution. We would
be grateful for any additional payments.
India :
Ordinary membership (those who live Dr. Abhay Bang,
Friends Medico Circle,
in Asia):
Gopuri, Wardha 442001.
Organization and
USS 25.00
Japan:
Dr. Hiromi Kawahara,
Director, Asian Health Institute,
Hara Hospital,
3—17 Wakatake—Cho,
Chikusa-ku, Nagoya 464.
Korea:
Dr. Kim II Soon,
Professor and Chairman,
Department of Preventive Medicine,
Yonsei University College of Medicine,
Yonsei University, P.O. Box. 71,
Seoul.
(or equivalent in
local currency)
USS 10.00
(or equivalent in
local currency)
Dr. Prem John,
Deenabandu Medical Mission,
R.K. Pet 631 303,
Tamil Nadu.
Philippines:
Dr. Manolet Dayrit,
c/o Dr. Mite Pardo de Tavera,
AKAP, 66 J.P. Rizal St.,
Project 4, Quezon City.
Friends of ACHAN (those living outside
Asia)
Organization and
USS 100.00
Programme
Individual
USS 25.00
Indonesia:
Dr. Lukas Hendrata,
Director,
Yayasan Indonesia Sejahtera,
P.O. Box 3028,
Jakarta.
Sri Lanka:
dr. V.L. de Silva,
117 Uyana Road,
Lunawa, Moratuwa.
These dues cover the period until De
cember 31, 1983. Checks are made pay
able to ACHAN. They may be sent to
our Hong Kong office at the following
address :
Dr. H. Kusnadi,
P.K.U. Mohammadiyah,
Jalan Menteng Raya No. 62,
Jakarta Pusat.
Programme
Individual
(
Thailand :
Dr. Sant Hathirat,
387, Soi Soon Vijai 4,
New Petchburi Road,
Bangkok 10.
ACHAN,
Flat 2A, 144 Prince Edward Road,
Kowloon, HONG KONG.
------------- - ----- - ----------------------------- i
8
Vol. I No. 2 Sept/Oct. 1981.
Newsletter of the Asian Community Health Action Network.
national policy to train community
health workers in India is one example
of the impact of non-government
ACHAN, as most of you know, programmes who experimented with the
was established .to answer a need of CHW’s long before government had any
people and programmes in the non interest.
government sectors for exchanges of
The greatest value of the volun
materials, information, personnel and
tary agencies is that they are concerned
ideas. However, the network encour
with people. They are able to live and
ages members from government offices
work with individual persons rather
and recognizes the importance of
than a whole bureaucratic system which
governmental resources and programmes must be seen to be giving all persons
in improving the health of the vast equal access regardless of need or
majority of the Asian people. The
interface and interaction among the
voluntary agencies and government de
partments is one of great interest to
ACHAN. For this reason, our “Feature”
this month begins an exploration into
these dynamics by focusing on the
case study of India. Written by ACHAN
executive committee member, Prem
John, it is the first in a series of articles
to look at this relationship.
income. The voluntary agencies have
had an important impact on moving
government priorities from curative
institutional care to community health
in many countries. ACHAN seeks to
support this movement and support
the voluntary agencies in exchanging
ideas about how their impact on govern ment can be the greatest.
There is no doubt that the majori
ty of expenditure for health services of
a nation must be borne by the govern
ment. Only the government has the
necessary income and resources to
provide a nation-wide health network.
In many Asian countries in the past,
voluntary agencies notably the Christian
Church, supported a sizeable portion of
nation-wide health services. However,
with the emergence of Asia from a
colonial era and a strengthening to
national independence and pride, Asian
countries now have both the desire and
responsibility to provide adequate
health care for their nationals.
ment2. This article seeks to analyse
the present trends, the past statistics
and plans for the future as expressed;
by both the government and the,
voluntary sectors.
Editorial
Susan B. Rifkin
ACHAN Co-ordinator
Feature
Tte [rtatt Care System
m Moa ■=> Bra Owwhs
“.......... medicine............ superb in its
technological breakthrough but woe
fully inept in its application to those
most in need”.
- Rex Fedall 1
Prem Chandran John
The health care situation in
India today truly reflects Fendall’s Inequitable distribution of resources:
concern.
A system that is wholly
Thirty four years after Independ
inappropriate for the needs of the ence, the health care system continues
majority has been allowed to flourish. to be broadly patterned on the colonial
A ‘Western’ scientific approach has system with very few modifications.
produced a view of health and a system It was assumed that ‘medical inter
of health care delivery which is accept ventions’ i.e. training of doctors and
able and available to a minority of other health professionals, provision of
people and often only to those who services and taking of modern medicine
into the countryside will improve the
The voluntary agencies still have have financial resources to afford
health status of the majority. (Table I)
an important role in national health doctors, drugs and a healthy environcare.
Because of flexibility, their
1947
1980
committment to the poor and oppressed
No. of Medical Colleges
29
106
and their new and innovative ideas, they
Table I
No. of Doctors Registered
47,500 253,631 (1978)
often chart new directions for govern
4
No. of Dental Colleges
15
ment health care delivery system. The
No. of Dentists
1,000
7,419
Not taken into significant account
Very often though, these centers proved in some institutions and some
was the inequitable distribution of were situated in unlikely places as a sectors, but the average has declined
health professionals, then and more so, matter of political expediency and were considerably because of the prolifer
now. That 80% of the doctors are con subject to enormous interference by ation of sub-standard institutions (that
centrated in the larger towns serving a various functionaries of the Government is what has happened in all branches of
population of 20% while 80% of the which impeded their usefulness8. Not higher education). The medical educa
population of India lives in the villages taken into account was also the fact tion system and the health care delivery
has become a well worn cliche but is a that doctors when posted to rural areas system have each gone their separate
painful fact. Also, out of those who went on leave, practised in nearby ways. There is little congruence be
register, migrations and deaths are not towns (since private practice is permitt tween the role of the physician and the
removed and continue to stay on the ed by many states), and in many in needs of society, little equilibrium
register. Under the circumstances, to stances, spent only an average of one between medical education and health
say that India has achieved a doctor- hour in the PHCs per day. (For a fuller care. Medicine is still regarded essential
Population ratio of 1:4,500 is a delusion account please see ‘The Health Center ly as an enterprise of science and
but increasingly quoted by knowled Doctor in India, 1972, Johns Hopkins technology.
The physician is the
geable circles to the world at large. University Press’).
repository of all knowledge and dis
(see Table II)3
pensation.
This paradoxical situation is also Medical Education:
Specialization is the hallmark of
seen in the statistics relating to hospitals,
(see Table III) beds and registered
nurses.
An earnest attempt at providing
medical care to the rural communities
was made with the introduction of
Primary Health Centers (PHCs) designed
to serve populations of 100,000 each,
roughly based on the National Develop
ment Blocks4.
Medical education in India (which progress; and the training ground is
is another topic that deserves in depth the teaclring hospital. Recent efforts
treatment by itself) continues to be to change this unhappy situation to
curative oriented, urban based, almost produce the ‘right’ kind of doctor and
a personal fiefdom of the ruling elite to give a community orientation to
and out of touch with the realities of produce the ‘right’ kind of doctor and
rural India. Inspite of all expansion, to give a community orientation to
doctors are still largely urban-based; medical education have yet to make any
and their distribution between different meaningful impact3.
Thus indicts
states is uneven. Standards have im “Health for All”.
Table V
Per capita expenditure on Health
Table II
Population
Doctors
Doctor-pop. ratio
660 million
(1979)
Rural 80%
Urban 20%
235,631
1:4500
20%
1:20,700
80%
1:1,300
1950
6,168
113,000
1977
17,607
449,212
7,000
120,401
Year
1956
1961
1966-67
1973-74
1974-75
1975-76
Table III
No. of Hospitals
No. of Hospital beds
Distribution Urban 90%
Rural 10%
No. of Nurses
r,. . ., ..
Urban 90%
Distribution „ ,
Rural 10%
1
No.ofPHC’s
No. of Sub-centers
1951
Nil
Table VI
Outlays on the. Health Sector
Plan
Table IV
1961
2,800
1971
5,195
'32,218
1979
5,423
40,124
Per Capita Rs.
1.50
2.35
3.79
7.72
9.47
10.63
I
II
III
IV
V
Total
% of total
(in millions of Rupees) Plan outlay
1,009.0
2,378.2
2,255.6
4,335.3
7,960.0
4.98
4.58
2.60
2.14
2.13
Resource allocation:
is not surprising therefore that the care being out of the reach of the
pattern of drug production is very common man in the absence of concert
similar to that in the West and reflects ed efforts at analysing and identifying
the needs of the richer, longer living forces which cause ill-health, that arc
Euro-Americans, while diseases of po primarily socio-economic. If, as Mahler
verty get scant attention (e.g. Dapsone says, “Health is politics on a Social
for Leprosy and INAH for TB are Scale”, what are we doing about it in
India? Are the present health plans
The apparently impressive in- constantly in short supply.)
including “Health for All An Alter
increase of per capita expenditure from
Rs.150 to Rs.10.63 and of the alloca
The medical profession, actively native strategy” relevant to the needs
tion from Rs. 1009.0 million to Rs.7,960 in collusion with the drug industry and of the country? What has been the role
to the Health Sector does not accurately aided by Madison-avenue type of of Voluntary Agencies in health care so
reflect the situation. The purchasing advertising, and pushy medical re far and what should be their role? We
power of the Rupee has declined presentatives, tend to over-prescribe, will seek to analyse these in the next
proportionately (to the present Rs.0.24 resort commonly to multiple drug installment of this paper.
in relation to 1954 base)6 and the po regimens when a single drug would do,
pulation has increased from 350 million use combination drugs when not in
to the present 686 million. Thus we dicated (eg. Tetracycline + Vitamin C
probably spend the same amount on separately and generically are 50%
health as we did in 1956. Of more cheaper than the combination Restecconcern is the disparity in allocation lin), and have developed the habit of
between rural and urban areas. Only prescribing glamourous brand name
1/5 of the total health budget goes drugs promoted by multi-national com
directly towards rural health care while panies. As a result, most prescriptions References:
“Health: The Human Factor” —
4/5 go towards maintaining sophisticat are beyond the reach of the common
1’2 ‘Contact’ Special Series, June 80
ed facilities inaccessible to the majority man.
World
Council of Churches,
(for e.g.in the IVth plan out of the total
Geneva.
outlay of Rs.4333.53 million only The Common man:
3
“
Health
for All - An alternative
Rs.700 million was allocated for rural
Who is this ‘Common man’? The
strategy” Indian Institute of Ed
health care). Also to be taken into
ucation, 1981 - Distributed by
account is the increasingly large (from Reserve Bank of India in a recent study
Rs.4.0 million in this 1st plan to Rs. has found that 75% of the rural poor
Voluntary Health Association of
3,009.3 million in IVth plan5) and live below the poverty line. This is
India, New Delhi.
often wasteful allocation to Family corroborated by the Planning Commiss 4
Pocket
Book of Health Statistics
Planning. (Of interest also is the esti ion which says that those living below
of India Central Bureau of Health
mate that over 75% of the health budget the poverty line have crossed the mid
Intelligence, 1976,Government of
goes towards salaries and maintenance way mark and for the first time con
India, New Delhi.
12% towards transport and 12% towards stitute 50.26% of the population.11
Various Plan Documents - Govern This large segment of the popula 5
drugs leaving little for innovative
ment of India.
community care). The point is, that in tion does not earn enough to have
terms of real allocation it has probably purchasing power to provide themselves 6
“On the Incidence of Poverty in
with even 1500 calories per day per
remained at the same level since 1956.
Rural India”, 1971, P. Bardhan,
head.7’10 The planning commission
ISI Planning Unit, New Delhi.
Drugs:
also says that at the prices prevailing in
7
Poverty in India - M.L.Dantwala,
“Health for All” puts the situa 1980, this level is pegged at Rs.660 per
1973, MacMillan India Ltd.
tion pertaining to drugs and their availa head per annum.5 Various surveys by
The Health Center Doctor in India
bility succinctly. “It is not enough to various agencies show that the great 8
1972, Johns Hopkins University
see that drugs are produced by Indians majority in rural areas live on about 50
Press, Baltimore.
and in abundance. It is even more paise a day per head10. That leaves
important to see what drugs are produc little scope for them to compete in the 9
Poverty in India, Dandekar &
ed and for whom.”3 Out of a total same market for services and goods
Rath 1971,EPW, Bombay.
production of Rs.lOOO/million (in 1976) pertaining to medical care. The un
10
Church and Social Justice - CSI
25% was taken away by vitamins and controlled market economy patterned
Synod Bangalore, 1976.
tonics, 20% by antibiotics4. The drug on the ‘capitalistic’ West in the face of
The Statesman, Calcutta 19.3.81.
industry in India is patterned on the wide disparities has left the majority of 11
West and in many cases depends upon the population to the tender mercies of
the West for ideas, raw materials, the the cartel consisting of the drug in
latest technology and marketing techni dustry - drug stores - and the medical
ques through their parent companies. It profession. This has resulted in medical
The “health plan” in India is
conceived by the Central Government
and implemented largely by the States.
Both the Centre and the States expend
money on health.5
3
AKAP’s professional staff is one of Training
health promoter, trainer and resource
Training is done in the comm
person.
unity. A requirement for establishing
better rapport with the community is
Programme : AKAP
for the training staff to integrate with
Personnel in the Programme
Director
: Dr. Glorioso V. Saturay
the community so as to understand
Organization of the community is
their
needs and devise methods how
Address
: c/o Dr. M. Pardo de Tavera the role of the community health
best to reach them within the frame
Chairman, AKAP
educator.
work of their culture, beliefs and
2226 Paraiso St.,
Dasmarinas Village,
The volunteer community health superstitions.
Makati, Metro Manila,
workers (CHWs) elected by the comm
Training materials have been
PHILIPPINES.
unity receive training in health-related
adapted to the comprehension level of
issues and in primary health care after
Short Description of the Pro
the recipients of the program and is
first being made aware of the problems
based on an evocative method.
gramme:
affecting their lives and community.
AKAP is a private non-profit,
From trainees the CHWs later Finances
non-stock, organization duly registered
become trainers.
Entirely from private donors.
under the Securities and Exchange
The brunt of the training is done
Commission designed to meet the vast
health needs of the poor especially by the nurse/health educators. Up Ways of achieving self-sufficiency
grading, re-training and keeping opt
those in rural areas.
Through contributions of the
imum standards is another responsibility
community members for health services,
of the nurse.
Short History of the Programme
medicines received are used to fund
The regional physician participates their health program.
In 1974 a 3-year research pro
gram was initiated in urban/rural in ground-breaking i.e., introducing the
The health workers do not receive
depressed areas with the objective of program maintaining good working renumeration for their services. In
testing the operations of a TB-control relations with community leaders,health return for their time the community
program within the framework of a agencies, establishing linkages, assisting assists the health workers in endeavors
primary health care community-based in trainers-training and supervising the from which they are kept away from in
program.
program, (see Appendix A)
the discharge of their duties.
There is a training team who aside
Based on these experiences AKAP
was organized in 1978 and a larger scale from supervising the areas responds to Evaluation methodologies
version of this program was designed to the needs of other communities and
Evaluation is done by the comm
organizations interested in adopting the
meet the health needs of rural people.
unity itself through a series of dialectic
same program.
sessions. Strong and weak points of the
Social Context in which Pro
program are openly discussed. SelfArea of operation
gramme operates
criticism is part of the process. These
Through
numerous
linkages meetings are held periodically with the
In selecting areas the choice was
narrowed down to depressed rural areas AKAP is involved in propagating the visiting AKAP staff.
|
with scarce or non-existent health program and directly or indirectly
facilities with overwhelming problems involved with many programs through Relationship with government
of malnutrition and a high rate for out the country.
agencies
communicable, preventable diseases.
On the whole there is a workable
The types of services are:
relationship with government health
Objectives
a)
training of CHWs, health profess agencies.
In areas where they are
To provide an effective low-cost
ionals and other sectors in pri unable to penetrate for lack of man
community participative, self-support
mary health care.
power AKAP’s services are welcomed,
ing program to cover the primary health b)
rendering health services to econ in fact, sought by the local health units
needs of people with special emphasis
who for lack of manpower, technology,
omically depressed areas.
on the control of TB and other comm c)
conducting research on various medical supplies and laboratory facilit
unicable diseases.
aspects of the prevalent health ies make use of AKAP’s resources.
problems and needs for the
Structure of the Programme
purpose of identifying possible’
Significance of the Programme in
solutions.
Since eventual self-reliance is the
relationship to government
basic principle of AKAP’s community
based health/TB control program, local Target Groups
To use the words of UNICEF and
Rural people who are beyond the 1 WHO, AKAP is a bridge between
support and participation is the main
thrust of the program, the role of reach of government/private health.
; government and people and, therefore,
Program Report
partners in the government’s endeavors APPENDIX A
failed to do so TB has reached the status
to reach more people especially in line
of being a family disease widely spread
with their primary health care program. TB TRANSMISSION IN THE PHILIP in cities and communities. Moreover,
PINE SETTING ENVIRONMENTAL the indications are that the incidence of
Achievements
TB is increasing and not decreasing.
AND SOCIO-ECONOMIC FACTORS
*
AKAP has shown the workability
of CBHP (Community Based Health
M. Pardo de Tavera, M.D.
Program) using local manpower resourc
es and adapting to the prevailing situa INTRODUCTION
tion.
There are rare occasions when one
In the field of TB control the feels truly honored, like this morning.
results obtained support the stand that Selected from among many TB special
in developing countries with budgetary ists to speak on tuberculosis, and the
constraints and plagued by problems environmental and socio-economic
of maldistribution of health personnel, factors affecting its transmission rate.
widespread poverty, malnutrition, a Rather curious that among the speakers
high rate of communicable diseases and I should be the lone representative from
overpopulation, a CBH Program in the non-government health sector per
volving people is the rational approach haps expected to be less restrained in
to meet the basic health needs of people. my assessment.
Shortcomings
PART I
1.
ENVIRONMENTAL
/ SOCIO
Erroneously, TB was viewed as a
medical problem and, therefore, we
searched for and applied medical
solutions forgetting that TB is a social
disease requiring socio-economic solu
tions of a preventive and curative nature
aimed at improving the quality of life of
people.
Curing the environmental/
socio-economic ills is as important as
medical treatment. TB and poverty
are intertwined. Poverty breeds TB
and TB breeds poverty. Drugs, super
specialists, clinics, hospitals, centers do
not cure poverty.
Tuberculosis is unique in that it
exposes the defects of a social system.
It is a social disease, the underprivileged
being particularly susceptible to it. The
“haves” are those possessing material
means, as against the “haves-nots”.
Another dimension to this is that the
“have-nots have TB” and the “haves
don’t have TB”.
Because of different ethnic groups
ECONOMIC FACTORS.
in the country the approach has to be
To begin, let us take a critical
modified and adapted to suit the comm look at the prevailing TB situation.
unity in question.
Despite the millions spent to control
TB, WE HAVE FAILED in our efforts
Plans for the future
for many reasons. The persistence of
From the viewpoint of the social
To attempt setting-up other TB, its high mortality and morbidity scale, the poor are the more prone to
models, such as a multi-disciplinary rates as compared to our ASEAN diseases and malnutrition. Their en
approach to health involving agronutri neighbors is reflective of our ailing vironment is hostile. Their lives are
tionist, community developers, veterin health/TB delivery system.
miserable, subjected to a constant
arians, environmental sanitation, co
We developed specialists when we scarcity of essential goods, facilities
operative expertS'the thrust of such an should have developed generalists, in and money, a high rate of unemploy
approach being more health-promotive order to meet the challenge of a prime ment or underemployment, inadequate
disease among Filipinos, a problem of health facilities, illiteracy, ignorance,
and disease preventive.
alarming and serious proportions and isolation of communities by distance
consequences.
and poor communication, inequitable
Things possible for Programme to
Instead of fighting TB within the land distribution and tenure systems
share
rigid walls of hospitals and centers prevalent in a rigid class structure.
Training materials and a modest we should have been right there where These are people who are not heard, are
amount of expertise.
not represented and have no-say nor
the action is — with people.
Lamentably, the curative approach influence in shaping their lives and
Needs of Programme
to TB received maximum attention, future. They live in a “rut” from birth
Funds to conduct field researches over and above the public health/pre- to death.
on various aspects of the program, such ventive approach. In our haste to
The single most important factor
as, the application of folk medicine in emulate sophisticated western methods influencing the mortality rate is the
present-day primary health care pro that tend to favor the institutional/ deficient nutritional state of the de
grams, search for ways of controlling curative approach we forgot the time- prived sector of the population. Riding
malaria and other protozoan diseases honored proverb that “an ounce of on the crest of malnutrition is tuber
other than thru chemical means.
culosis. TB and malnutrition are the
prevention is worth a pound of cure”.
result of poverty, squalor and ignorance.
Since TB is a threat to the health
Other Comments
Overcrowding brings people closer
of people, instead of curing TB on a
AKAP looks forward to the case-to-case basis we should have together, which favors a high incidence
creation of a resource center on Asian adopted a more relevant strategy, a of airborne infections like TB. Visualize
community approach.
Because we one-room barong-barongs measuring
Primary Health Care Programs.
5
3.
A REFORMED
SYSTEM.
HEALTH/TB handwriting was on the wall but it was community. Approaching TB on an
ignored.
individual basis achieves-only individual
People are aware of their health TB cures. But what we need is to
requirements but do not possess the control TB on a nationwide basis. The
necessary skills anymore. At one time, methodology for TB control consists
one or two generations before, they had of: health education, BCG vaccination,
been able to attend to common ailments case-finding of contagious cases by
through the use of medicinal plants and sputum microscopy and adequate treat
applying hand-me-down household re ment of all infectious cases.
Controlling TB has become a
numerical nightmare. On one hand, we
have a widespread communicable dis
ease responsible for “an annual loss to
the economy of 600 million pesos, and
on the other hand, a centralized rigid
health system saddled with budgetary
limitations, shortage and maldistribu
tion of health manpower, not enough to
meet the demands of such a big health
problem.
medies. Carried by the wave of wester
CONCLUSION
nization all this was forgotten or dis
paraged.
The poor were left with
Independently and unknown to
nothing except dehumanized, offending each other a small band of disenchanted
It is felt by the pioneers in pri “charity services” inaccessible to most. health professionals turned their backs
mary health care in the country that, in Only the economically favored could to the conventional practice of their
order to effect a reform in health care afford the high cost of drugs and vocation, from the curative approach
to health promotion. This was less than
it is necessary to effect a change in the medical care.
a decade ago. Despite the traumatic
social/cultural structure. Instead of
To be successful, a health program
personal experiences of steering away
dictating and imposing a health system should be patterned after the life style
from the “establishment”, the driving
with people as passive recipients the of the people it is designed to serve.
force was compassion for the poor and
thrust should be to involve people as Teaching aids should use symbols they
the meek scattered throughout the
active participants in planning and understand. Teaching should be based
countryside representing the majority of
promoting community health.
The on an evocative method so as to elicit
the population and for whom the
spirit of “one for all and all for one” response for it is through response that
existing sophisticated medical system
has to be instilled and hitched to a barries are overcome.
had not been designed to serve. The
higher ideal.
Since TB has reached the status of evidences supportive of this statement
Initial efforts in community- being a prime disease it is our opinion are undeniable. They are day-to-day
based health program saw its genesis in that TB control services should be reality and passively accepted as a waythe local scene, in 1974. At the same available at the primary level. The of-life. Foremost among the endemic
time the Alma-Ata conference on Carmona experience has proven that communicable diseases sapping the
primary health care was held in Russia primary health care/TB control program strength and decimating our people is
in September 1978, a report was read in of people and by people is feasible, in tuberculosis.
Brussels at the International Union expensive and assured of success.
In the field of TB great discoveries
Against Tuberculosis based on a re Properly trained and supervised volun
have been made. We know what causes
search entitled, “A model of comm tary community health workers are the
TB. We know how it is transmitted and
unity participation in the prevention best harbingers of health. They have a
how environmental and socio-economic
and short-term therapy of TB among way of echoing and reechoing health
factors favor its transmission. Further
the poor in Asia - A Philippine ex messages that are easily understood. more, we know how to prevent TB;
Power is with people. Properly guided,
perience”.
how to cure TB. Equipped with all this
This research proved that if only people can transform society.
technical knowledge we should have
people are properly motivated they are
In primary health care/TB control controlled TB like many of our ASEAN
willing and eager to accept the responsi programs, nurses are best suited to neighbors but have we? Awareness of
bility of their primary health care. The perform the functions of generalist, the shortcomings of the national TB
motivation goes beyond the health educator, motivator, supervisor and control program in terms of its imple
program because it symbolizes people’s organizer. They have the capability to mentation has not effectively dented
struggle to free themselves from the harness the potentials of people. Their the armor of resistance to change. In
bondage of ignorance, poverty and educational background has well pre fact, the few who have dared to speak
disease. It embodies an ideal bigger pared them to expertly deliver primary out the truth are not looked upon with
health care from the comprehensive, favor for truth hurts.
than self. This is the driving force.
preventive, promotive and rehabilitative
Looking beyond constructive cri
From a rigid centralized health approach to simple curative and em
system the wind of change is towards ergency interventions. The nature of ticisms and theories and in search for a
decentralization involving people. It is a their profession has identified them new direction efforts were exerted in
health program of people, by people. In closely with people, with the human delivering TB services together with
primary health care. The results obtain
many ways it is humanizing a system more personal side of health care.
ed in poor communities proved the
that has become insensitive and im
TB is not the exclusive problem wisdom of bringing the health program
personal. The change was predestined
to
the level of the community and
to occur because of people’s growing of an individual. His problem is the
dissatisfaction with health services. The problem of his family, contacts and through community participation. It
7
8
ACHAN Plans and Programs
When the ACHAN executive
committee met in March, it was asked
to consider the possibility of jointly
sponsoring with an ACHAN member,
the Rural Unit on Social and Health
Affairs (RUSHA), India a consultation
on the possibility of creating a course
for rural community health managers
in Asia and particularly India. After
discussions, it was agreed to join the
sponsorship of this consultation. It
will take place in India in February,
1981.
government community health pro
grammes. The general objectives of the
course are to train people to do the
following:
1.
The consultation is the result of
many years of interest and experience
of the Voluntary Health Association of
India (VHAI). VHAI is the largest
co-ordinating body of non-government
health programmes in India and is a
strong supporter of community health
as defined in the ACHAN consultation. 2.
For some time now, VHAI has wanted
to create a training course for local
people which could teach people how
to become good managers of rural
community health programmes in the 3.
same manner that it taught people to
do good hospital administration. It
saw no reason that it was necessary to
send people to countries, like the U.S.
and the U.K., to get training in condi
tions almost totally opposite to those
existing at home.
After several experimental courses
including short term training and an
internship programme which lasted one
year, it was decided to create a course
equivalent to a diploma in health
management. The site and administra
tion of the first course is to be RUSHA
in K.V. Kuppam North Ascot District,
Tamil Nadu.
The training course would be
useful to people who are managers and
leaders in both voluntary agencies and
Ask effective questions (a) about health issues in the
country;
(b) related to socio-economic
and political systems of the
national level and how these
affect local community;
(c) which challenge people to
think about and find solu
tions to their problems;
(d) which lead to the creation of
true communities with com
mon purpose and goals for
the betterment of the life of
all members.
(e) ability to discover and under
stand the special dynamics in
any situation affecting the
health and development of
the people.
4.
Act as a change agent in order to
make health a means and a
measure of development.
5.
Understand the team concept, and
will have shown the ability to take
a leadership role in the team.
It will stress learning experiences
rather than methodology and stress field
rather than classroom. It is hoped that
based on the RUSHA experience, other
training centers will be established in
India.
In light of ACHAN’s training
Use problem-solving methods in priority and the recognition of the
necessity
of training people who can
cooperation with other team
members and in collaboration function in their own existing rural
conditions
not in the medical schools of
with communities to find solu
the Western countries, the ACHAN
tions to common problems.
executive agreed that sponsorship for a
Plan, organize, implement and
consultation on developing a curriculum
evaluate community health and
for the RUSHA course would be an
development programmes effect
appropriate ACHAN activity. We noted
ively through
that RUSHA wished to train others in
(a) ability to relate effectively to addition to Indians and expressed a
strong
desire to get advice from other
communities;
(b) assisting communities in iden Asians about how to make the training
appropriate.
Thus, it was decided to
tifying their needs and re
sources and organizing them help RUSHA with fund raising for the
consultation
and
with suggestions of
to become actively involved
in their own health and self appropriate Asian participants.
development;
The executive committee meets in
(c) providing for technical as November in Madras, India at which
sistance needed to carry out time it will join VHAI and RUSHA for
programmes in the comm a three day meeting to further plan the
consultation. Reports of the consulta
unity;
(d) coordinating with govern tion itself will appear in LINK after it
has taken place.
ment and other agencies
needed;
Publications
This issue of LINK reviews some
of the publications available for training
community health workers.
Brown. Judith and Richard Brown.
Finding the Causes of Child Malnutri
tion. Task Force on World Hunger.
1979.
Available from. Task Force on World
Hunger, 341 Ponce de
Leon Ave., Altanta
Georgia, 30308.
Price: US$2.00
This Handbook is for Health
workers who want to attack ProteinEnergy Malnutrition of children in their
own communities.
This Handbook is written to help
answer 3 important questions:
I.
How do you measure community
malnutrition?
II.
What are the food problems in
your community?
III. Which problems should you
attack?
This Handbook is written in basic
English. A person who has finished six
years of school will be able to read and
follow this book.
Durana. Ines. Teaching Strategies for
Primary Health Care. The Rockefeller
Foundation, 1980.
Available from: The Rockefeller Found
ation, 1133 Avenue of
the Americas, New
York, N.Y. 10036,
U.S.A.
Price: no charge
This book is designed for trainers
of primary health care workers in the
developing countries and is to be used
by both the medical professional and
the non-physician. It presents ideas
on how to teach both social process
skills and technical health skills. Pre
sented in outline form, learning strateg
ies are given to help the user in teaching
the described skills in which the in
structor gives relevant exercises to the
trainee. It combines ideas on integrat
ing theory and practice of developing a
primary health workers training pro
10
gramme. It does lack, however, sugges Werner, David. Where There is No
tions on how to make the content Doctor. Hesperian Foundation, 1977.
relevant in local situations and tends to Available from: The Hesperian Found
ignore the social, political constraints
ation P.O. Box 1692,
on some of the ideas.
Palo Alto, Calif. 94302
or TALC, Institute of
Child
Health, 30 Guild
Morley, David and Margaret Woodland.
ford Street, London
See How They Grow. Macmillan, 1979.
WC1N 1EH, London,
England.
Available from: TALC, Institute of
Child Health, 30 Guild Price: Unknown
ford Street, London
This is the most well known and
WC1N 1EH, London, praised of the CHW manuals. Originally
England.
intented as a manual for CHW’s in a
Price: Unknown
voluntary community health programme
This book discusses in detail the in Mexico, it now has been translated
development and use of Road to Health and adopted in numerous languages.
Growth Charts developed by Morley. Geared to the circumstances and educa It uses this discussion to get involved tional level of rural village people, it
with wider mother and child care and explains in words and pictures how tot',
community health issues. The book is treat and care for the most common
It also discusses
designed for a literate group but to help health problems.
trainers teach primary health care prevention, use of locally available
workers how to use the growth charts. herbal treatments and health education.
It will be useful to those training people It has been a model volume for comm
unity health workers in poor rural areas
in MCH care.
throughout the world.
Rural Missionaries of the Philip
WHO.
The Primary Health Worker
pines. Guide to Community Health.
(Revised Edition), 1980.
2 vol. revised, 1978.
Available from: WHO regional offices
Available from: Rural Missionaries of
or WHO Headquarters,
the Philippines, 2215
1211 Geneva, Switzer
Pedro Gil, St. Ana,
land.
Metro Manila, P.l.
Price: 12 Swiss Francs or pounds sterl
ing, USS equivalent.
Price: about US$2.50 each
These two volumes provide both
the theory and practice of community
based health programmes (CBHP) and a
training guide for community health
workers. They contain articles which
argue the necessity of community
participation in health care by such
notables as Dr. John Byrant, Dr. Joe
Wray, Dr. J. de la Paz and Bishop
Layben. They also share the analysis of
the valuable experiences of the Rural
Missionaries in beginning to establish
community-based health programmes
with principles of community organiz
ation, selection of CHW’s and review
of training programmes techniques and
skills. The second volume is a text for
health knowledge most useful for the
CHW work. These two books have
provided textbooks for training CHW’s
in CBHP in the Philippines.___________
This working guide outlines the
structure and contents of training for “
the primary health workers on the
basis of the most common health
problems in developing countries.
Part I can be used by the primary
health workers as a learning text and
also as a guide in his work. Part II is
addressed to the health workers’ teach
ers, tutors and supervisors. Part III
discusses the adaptation of the book to
local conditions; this can be done only
in the country where it is used.
and working with traditional healers, there have been very useful dialogues
working through community selected and meetings between the medical
Aboriginal Health Workers, a high staff and the healers, although only on
emphasis on training and prevention rare occasions has the style of work and
rather than purely curative care. Euro relationships allowed the healer to play
ACHAN has received request to pean staff were to be appointed by and a continuing role as a health worker in a
The primary health
find people who might be interested in accountable to the community controll health centre.
ed medical service.
Although the workers are selected by the community
the positions described here.
Northern Territory Department of and the base of operation is the Hospital,
Health had been fairly supportive of which was unfortunately designed and
AUSTRALIA
moves to establish independent Aborig built by bureaucrats in Canberra and is a
Doctor with qualifications re inal Medical Services such as the Ura- real hindrance to getting the focus of
gisterable in Australia for work in an punga Health Service based on Utopia, attention on the community rather than
aboriginal tribal area 150 miles west of an Aboriginal owned cattle station, the health centre.
The Aboriginal
Alice Springs.
The programme is and the Central Australian Aboriginal Health Workers receive training at
government funded but is able to define Congress-Aboriginal Medical Service Papunya from the staff there which
its own health care policy on many which operates as a general practice in include a Health Educator who has
principles of community health in Alice Springs itself, there was opposi some equipment. A selected number of
developing countries.
tion to the idea of Papunya becoming Health Workers also come in at regular
an Independent Medical Service. After intervals to attend courses run by the
Programme description
a long struggle the Commonwealth Department of Health. The Aboriginal
Papunya Community is one of Government funded the community for Health Worker Training Programme has
four communities in Central Australia a medical service in 1978. The North been widely recognised as one of the
that is funded to provide its own ern Territory has always been known best things that the Department of
independent medical services. Papunya for attracting “missionaries, mercenar Health is doing. There are approximate
was funded for a medical service by the ies, or misfits” and staffing of the ly 150 Aboriginal Health Workers
Australian Commonwealth Government Papunya Health Service has always been employed and in training around
Central Australia some of whom are
because of the recognised problems that a bit of a problem.
the community has had over the twenty
The Nursing staffing situation is employed by the Independent Medical
years since it was founded as a show much more stable now and there is Services.
piece of the assimilation policy. Twen quite a good team there, but apart from
Although Papunya community
ty-one different extended family com one good year the community has had has quite a few amenities, a school, a
munity groups from five different difficulties in finding a doctor who good shop, regular films, sporting
tribal/language groups were compelled combined the necessary wide clinical facilities, with a permanent swimming
to move to Papunya in the early sixties competence with a passion for comm hole a few miles away, the atmosphere
and the last of the desert Pintobi people unity medicine and an ability to create is not as encouraging as that of the
who had never seen europeans before team work.
outstations where there is a vigour and
came into Papunya in 1965. As you
The conditions of the job are energy and optimism about the people
could no doubt guess both adult and
fairly good.
Accommodation and which is lacking at Papunya due in part
£ child mortality and morbidity were
vehicle are provided, salary and leave are to its oppressive history. If the doctor
high in the early years and the con
adjusted to the Department of Health and his family are able to form good
tinuing social pathology continues to be
relationships with aboriginal people
reflected by poor health, high rates of Medical Officer Class 2 level, namely then it will be a very enjoyable time at
malnutrition in children, abuse of A $25,000 to $28,500 per annum with Papunya. If they are not about to form
alcohol by adults and petrol sniffing six weeks annual recreation leave. The good relationships with the aboriginal
among kids. There has always been a doctors qualifications would, of course, people, then Papunya would have very
fairly high rate of turnover of european need to be registerable in Australia.
little to commend it in the long term.
More about Papunya. It is situat
staff there.
In 1975 the National
Health and Medical Research Council ed to a beautiful mountain range three
If you know of any doctors who
funded a study of Papunya to look at hours drive or 150 miles West of Alice would be interested in finding out more,
the possible benefits of an alternative Springs. The climate is an arid zone 1 would be grateful to hear of them or
approach to health care. The model climate with hot summers and cold enquiries could be directed to Dr.
proposed by the researcher Dr. Trevor winters, the rainfall is usually 8 - 12” Trevor Cutter, Central Australian
Cutter (who is currently Senior Medical per annum. About two thirds of the Aboriginal Congress, 78 Hartley Street,
Officer with the Central Australian community lives in Papunya itself and Alice Springs, N.T. 5750. Telephone:
Aboriginal Congress-Aboriginal Medical the rest live on outstations. Aboriginal (890) 523377, (A/H) 524537); or
Service in Alice Springs) incorporated ceremonial life is alive and well. There Dr. Hugh Nelson, District Medical
most of the generally accepted principl are a number of very skilled and ex Officer, Department of Health, P.O.
es of appropriate health care in develo perienced and respected traditional Box 721, Alice Springs N.T. 5750; or
ping countries, — namely respect for healers or Nangkaris and in the past direct to the community.
Positions
Vacant
advantage of them. At the same time, The resident extensionists can call
the private economic sector is more upon a pool of specialists from the
responsive
to power and leverage which VDTP headquarters staff as needs
A health planner/trainer is needed
The program encourages the
for a village development training the poorer villagers simply do not arise.
programme in northeastern Bangladesh possess. In the VDTP, the emphasis is formation of village organizations in order to respond to village develop on making services readily accessible — cooperatives, mothers’ clubs, youth
ment needs in 25 villages by providing with extension workers based in the clubs — which can be focal points for
extension and advisory services. The villages — and on organizing community production and training. The organiz
major health activities included mater groups through which needs can be ations are also proving effective in
nal and child health, family planning, articulated and assistance channeled. increasing the villagers’ access, on more
nutrition and hygiene. The focus is on FIVDB hopes that the VDTP can be of favorable terms than before, to needed
developing village self-reliance for their immediate, practical benefit to the goods and services from both the
health needs. The ideal person would villages where it operates; and that the public and private sectors.
have a degree in public health or health program will demonstrate a viable
Secondly, the program provides
education, three or more years field alternative structure for service delivery field training for trainee development
experience in a developing region and that might be used elsewhere by Govern workers from three local Government
experience in planning and training ment to make its national programs institutes in Sylhet District: the Rural
more effective at the village level.
para-professionals.
Development Training Institute, the
The VDTP, as its title implies, has Agricultural Extension Training Institute
Programme description
and the Family Welfare Visitors Train
a dual purpose.
The Village Development and
The program, operating in some ing Institute. As part of their course
Training Program in Sylhet District in 30 villages in Kotwali Thana of Sylhet work, the students spend up to three
northeast Bangladesh is administered by District, is primarily designed to help months in village homes as arranged
Friends in Village Development Bang poorer villagers meet their basic needs by the FIVDB staff; and work alongside
ladesh, an indigenous private, non and improve their living standards. the local villagers and the FIVDB staff.
profit agency established in 1979 and Service centers have been set up in each The experience gives the students a
officially registered in 1980. FIVDB, of three “clusters” of villages, and direct and practical appreciation of the
formed from among senior Deshi multipurpose development workers,. possibilities for closing the gap between
staff of IVS, assumed full management based at these centers are available to village needs and relevant Government
control of the VDTP in January 1981.
counsel villagers on their problems. resources.
BANGLADESH
In Bangladesh, as in many parts of These resident extension staff offer For further information, write:
Mr. Lynn Ellington,
the world, poorer villagers all too often advice and assistance in agricultural
International Voluntary Services, Inc.,
fail to benefit from Government techni production (rice, vegetables, fish culture,
1717 Massachusetts Ave. N.W.,
cal and social service programs because duck-raising etc.); health and family
Washington, D.C. 20036,
the administration of such programs is planning; functional education and
U.S.A.
remote and fragmented, and villagers literacy; and activities like handicrafts
are not sufficiently organized to take that can yield a cash income for women.
12
National Conference on Evaluation of
Primary Health Care Programmes
April 21-23, 1980
Abstracts
INDIAN COUNCIL OF MEDICAL RESEARCH
NEW DELHI
G-vV
COT""''- ■
5S0 001
PRIMARY HEALTH CARE TO URBAN SLUMS - EXPERIENCES AND EVALUATION
by
Dr. N.S
*
Deodhar, Director,
All India Institute of Hygiene and Public Health,
110 - Chittaranjan Avenue, Calcutta.
Since independence, there has been tremendous and
rapid expansion of the health services for the rural areas
in India. A network of primary health centre complexes was
established, and has been functioning during the last 25 years
or so
*
In addition, many national health programmes were
specially developed to deal with some specific public health
problems. Although there have been substantial gains in
improving health status of the people, there is a growing
concern about the ineffectiveness of the existing health care
delivery system to provide primary health care to all, especi
ally to the underprivileged and poor.
The Multipurpose Health Workers' Scheme and the
Community Health Volunteers' Programme were started with a
view to reorganizing the health services and ensuring community
participation in the task of health promotion through selfreliance. Embhasis has been always on the rural population.
However, the plight of the slum dwellers and urban poor is
perhaps worse than those of the poor villagers. It is often
observed that the slum dwellers in urban areas are not only
poor but are also socio-culturally maladjusted to urban life.
In the light of this, a project was taken for developing an
alternative model for delivery of health care to the urban
poor at the Urban Health Centre of the All India Institute
of Hygiene and Public Health, Calcutta. There have been
attitudinal, psychological, administrative and. social diffculties
that cropped up in the implementation of the programme. These
will be presented in the paper.
...2... .
Many experiments in primary health care
have been undertaken in India in different States.
These experiments have provided valuable experiences
which should serve as guidelines for development
of future programmes for improving the efficiency
of the health care delivery systems in the country.
Some of the experiences in this field, specially
in the process of evaluation of the Community
Health Workers' Scheme, will also be presented.
One of the basic problems is the lack of
primary concern in improving the efficiency of
the health care delivery system. It is noticed
that various schemes and programmes are being
taken passively and not with strong motivation,
or active involvement, or initiative.
SOME
THOUGHTS
ON
EVALUATION
by
Dr. K. S. Sanjivi,
The Voluntary Health Services Medical Centre,
Adyar, Madras - 600 020.
The evaluation should really start from the
top, the political and administrative leaders of
the Community.
Some of the problems connected
with evaluation at this level are discussed with
illustrative examples.
The evaluation of the workers at various
levels ending at the health post, most peripherally
is also dealth with as well as the community's
reaction to the health programme which can be done
in several ways, which are discussed.
SOME THOUGHTS ON THE STRATEGY OF EVALUATION FOR
PRIMARY HEALTH CARE PROGRAMMES IN DEVELOPING COUNTRIES
by
Er.S.N.Chaudhuri, Emeritus Prof.,
Institute of Child Health,
Calcutta.
Primary health care is basically a self-care process
where professional know-how and the lay interest should
interact for internalization of health needs and demands of
the community for their spontaneous management at the level
of individual micro-units.
This social control demands compliance, which can
only be ensured in a developing community through a
holistic programme, wherein the health-demand should be
integrated with other psycho-social needs of the community.
This bundle model with multidimensional interacting
components will be more acceptable to the indigent people
because some of the felt-needs with benefits known to the
people will facilitate adherance to the programme
*
Any
evaluative exercise should reckon these special and specific
features for proper alignment of variables and assessment of
outcomes as a developing continuum with different interme
diate indicator for different stages of development.
The appropriate method of analysis, establishment
of valid intermediate indicator, assessment of reactions
and suitable method for the quantification of popular
participation will form the special attributes and will
be discussed in the presentation.
ABSTRACT PAPER ON
DEVELOPMENT OP HE.-ilTH MANPOWER (ALLOPATHIC PHYSI
CIAN CATEGORY) FOR PRIMARY HEALTH CxxRE
By. Hr. S. Krishnaswamy Rao.
Growth of institutions since 1947 for training of physicians
of western system of medicine in India has been haphazard. It
the
lacked a conscious effort to fit-in/short-tenn policies and plans
to be in tune with the long term perspectives. This has resulted
in an uneven growth and development of medical colleges in the
country and a glut in the market for physician manpower.
For any sensible planning a well designed and efficiently
functioning information system is essential. Here again no effort
is forthcoming in- that direction.
Compared to Nurse Manpower, the wastage in medical colleges
is minimal. This could still be bettered by improved selection
techniques and charging for more scientific techniques available
for performance evaluation of students.
The magnitude of withdrawal of physicians from the profession
in the country by emigration is of a sizeable order. This has
economic significance for the country.
Unemployment problem amongst the graduate and post-gi'aduate
level qualified physicians is rapidly mounting. While this being
so, states wiih high unemployment rate have kept positions
created for physicians unfilled. This is conspicuous in the
National Family Welfare Programme and Primary Health Care
Programmes.
While community preference for obtaining health services
from physicians of western system cf medicine is high, some
states have preferred to provide health services through
physicians of indigenous systems of medicine.
: 2 :
The unemployed, underemployed and recently employed
physicians in the governmental sector have been resorting in
some states to revolutionary methods to draw attention of the'policy
makers to undertake measures without delay to correct the
unemployment situation.
There is a big question as to why the problem of unemployment
amongst physicians should eveiL occur while this is a profession
which can stand, on its own when demand for their services have
been mounting rapidly.
It is no use talking of providing Primary Health Care without
a conscious health manpower policy and planning.
*****
Ak/
HEALTH SERVICE SYSTEM SUPPORT TO
PRIMARY HEALTH CARE PROGRAMMES
by
Hr. G.S. Mutalik, Director,
Development of Comprehensive Health Services,
World Health Organisation, World Health House,
New Delhi - 110 002. [India]
During the last decade, with the growing acceptance of
primary health care as a key alternative approach to meet the
basic health needs of the people, a very large number of
primary health care projects/programmes have, been developed
both by governmental as well as non-governmental agencies.
While conceptually most of these programmes attempt to effect
ively bridge the gap between the official health services ^nd
the community, varying stress in laid on the other dimension
of primary health care viz a dynamic and self-reliant movement
of the community itself towards the betterment of the quality
of life of its members through intersectoral integrated
efforts. Dor the successful delivery of primary health care
package to the doorsteps of the people through such projects
a. well-planned and coordinated .support from the health service
system is absolutely necessary. However, in practice, such
support is often unorganized, disjointed, ineffective and
generally not well-planned, with result that primary health
eare projects/programmes often develop a lopsided preference
for delivery of those components of the package which are
easier to deliver such as day to day medical care. Such
vital components as MCH, Environmental Sanitation including
Water Supply, preventive programmes often do not receive due
attention.
The organizational aspects of primary health care inclu
ding its implications to the health service system and its ..
interface with other sector interventions to ensure the
appropriate mix timing and emphasis to evolve an integrated
community development activity will be discussed.
RESEARCH on health survey techniques
[research on techniques for improving the
HEALTH DELIVERY SYSTEMS IN THE COUNTRY|
by
<£i
Dr. A.D. Taskar, Dy. Director,
Institute for Research in Medical Statist!cs,ICMR, New. Delhi.
There is a growing demand and concern to improve the
delivery of health services in rural areas in our country. Many
health administrators have realized the inadequacy of the exist
ing primary health centre complex to cover the population
effectively, although they are providing some curative health
services. It is also felt that increase in staff strength is
not the best solution to improve the outreach. This has brought
to find
out the necessity/alternate strategies to evolve, implement and
evaluate a second line in health services delivery presently
done by the PHC personnel. The rural school may be one of the
ideal portal of entry to the rural community. To evaluate the
effectiveness of involving the school teacher in the delivery
of health care to the rural population, the ICMR initiated a
collaborative research project during the year, 1976 with the
objectives of: i] to study the feasibility and effectiveness
of involving school teachers in the delivery of specific compo
nents of health care to communities through the existing PHC
set up; .ii] to identify the specific roles and tasks that can
be performed by school teachers in health care delivery and to
develop training program, (including job descriptions and a
mechanism of supervision of these task); iii] to assess the
relative effectiveness of teachers in their specific roles in
relation to health education and health care delivery tasks
under varying inputs, like training and incentives, training
only as compared, to control; iv] to identify problems of
teachers in performing their role; and ( v) to suggest metho
dology for involving school teachers in delivery of health
services, based on the findings of the study.
-:2:~
The study is being carried out at three
centres viz. National Institute of Health and •_
Family Welfare, New Delhi, Rural Institute of
Health and Family Planning, Gandhigram and
Mahatama Gandhi Institute of Medical Sciences,
Sewagram. The study was planned under three
phases i.e. Diagnostic, Intervention and
Evaluation phases. At present the intervention
phase is under progress.
The study is planned as a randomized
control trial with having both Control and
Intervention areas. The Intervention areas
will have a package which consists of trained
school teacher in the health care delivery,
provision of drugs and incentives to teachers/
schools.
The study has evolved a curriculum for
training of school teachers and a set of para
meters for measuring the effectiveness of school
teacher in rendering the Primary Health Care.
The methodology of evaluation of primary health
care through school teachers adopted in the
present study will be described in detail.
0?,
Reprinted from the Proceedings of the VII International Congress of Rural Medicine,
of the Congress held 17-21 September 197S, Salt Lake City, Utah, U.S.A.
COMMUNITY HEALTH SERVICES AS A COMPLEMENTARY FACTOR IN THE
PROCESS OF RURAL DEVELOPMENT WITH SOCIAL JUSTICE
E. B. Sundaram
I.
INTRODUCTION
Health is a God-given gift and it is often said that a person may
possess all the good things of this world and yet if he does not have
health he cannot live an abundant life.
Yet basic requirements for promoting good health are denied to
about 80% of the population, especially in rural India. WHO in 1970 after
an extensive survey made a revealing statement that 80% of the people of
India live in the rural areas producing 70% of the gross national product,
and only receive 25% of the health services. This is blatant social injus
tice. In other words, rural India is not only supporting the economy for
better living in the cities, but it is at a disadvantage due to lack of
health facilities.
The purpose of this paper is threefold:
1)
To examine factors which are necessary to develop a practical
role for health services in socio-economic development at the
micro level.
2)
To suggest how community health services can complement in the
total development at the micro level.
3)
To examine the specific role of community health services in
breaking age-old barriers so as to produce social justice.
l.a Factors necessary for a health care delivery system
[
Economists of developing countries have justifiably cautioned that
£
1
socio-economic development is more important than health services. This
trend is usually shown when budget allocations are made. It will be reacL>--'iily seen that at the national level in India 13% of the budget is alJoesfEed
-s .
to defence, and only 7% to health (Figure 1). This factor (one of Tne many)
f,
at the micro-level, has caused the following:
c
l.b Health services even at the district level, especially in Uttar
o <£
Pradesh are extremely disorganized and have not produced the desired result
£
even though on paper the organisational structure meets acceptable stan
dards .
5
l.c At the block level there does not seem to be an effective infrastructure, for example finances are not available to pay for several months
'■ «
the medical and paraprofessional workers. The budget for medicines amounts
§
to around Rs. 2,500/- per year, for a population of one hundred and twenty
■■■■ s o
thousand. A closer examination of a block shows that resources are availr ; w
able, but socio-economic development has not occurred at the rural level.
i? uj
A simple and adequate health service is possible as shown by many workers
■■■ □ §
in India, Africa, China, Thailand and Indonesia. Hence the main problems
can be categorised as follows:
?
o
l.d Lack of proper planning at the micro level.
£
385
l.e Whatever planning exists is so inadequate that large sums of
money are spent ineffectively. At many block levels we see beautiful
structures with insufficient budget for running a health programme. Or in
several blocks we have noted that large sums of money are spent for large
vehicles without adequate budget for maintenance or petrol. Hence, in
trying to develop resources at the micro level, due to the Government's in
ability to mobilise their own resources, effective health care delivery at
the infrastructure level has failed to a large extent. This failure has
caused very serious economic repercussions. Probably the best summary of
these factors has been given by the Intermediate Technology Group, U.K.
which has developed a "cycle of misery" which is explained in Figure II.
It is said that even though health programmes probably only contribute
about 30% to the economic growth of a population, it serves a very urgent
and acute human need of the community, which no other service can provide.
For example, if a person has a renal colic or a child has diarrhoea, or a
farmer meets with an accident, or a man has a heart attack, he will need a
hospital and the services of the medical profession to meet this human
need. Hence even though an economist may state that health programmes
should not be given priority, it has been noted that as the level of socio
economic development and education increases, a community will demand bet
ter health services. To put it in another way, health programmes are es
sential for economic development.
In several developing countries extensive studies have been made of
the economic benefits of health programmes at the micro level. These
health programmes have shown that the investment must be on man. For ex
ample, in Haiti it has been shown that a simple Yaws eradication programme
returned 10,000 workers to the labour force. Yaws is a disabling skin
condition of the lower extremities and can be very effectively treated with
penicillin. All that was needed was:
l.g Orgnaization,
l.h Provision of a simple budget,
l.i Paraprofessional workers trained to identify the condition and
treat the same effectively,
l.j An efficient follow-up system.
The economic benefits of a simple anti-malaria programme reduced
absenteeism in the Philippines from 35% to 4%. Hence even though there has
been a certain amount of uncertainty of the priority of the health pro
grammes, and serious doubts were raised of their contribution towards gene
ral development at the micro level, yet it has been proven that when health
programmes can be integrated with agriculture, education, small scale in
dustries and other social welfare programmes, the masses are lifted out of
general poverty and its consequences.
In analysing integration of health and development at the micro
level the basic results are shown in the following:
a)
In the child, it gives an opportunity for concentrating on his
education. Several times we see children in a village school who are illnourished and cannot concentrate on their studies. Their concentration
span is exceedingly low. They get tired very easily and the teacher has a
hard time trying to teach them even for a few minutes. These children are
usually found to be mal-nourished, with protein and multi-vitamin deficien
cies, and are unwilling to play games as they get tired very easily.
386
We cannot expect these children to grow into normal adults. The work of
Bacon Chow of Taiwan, and our own studies with the Japanese hospital at
Agra (Colombo Plan Experts) have shown that the grey matter of the brain of
these children does not possess the normal number of cells which are usual
ly found in healthy children. In other words, it has been shown that these
children, if they continue to be under-nourished, will have low intelli
gence quotients and the whole community can even develop into morons. It
is difficult for these children to grow into normal adults and develop
highly specialized skills for which knowledge is required. Scientists have
stretched a point by stating that it is not possible for developing coun
tries to produce many discoveries probably due to lack of proper nutrition
(probably this is only one factor among many others). In analysing the
economic growth at the micro level one finds the following factors inter
acting so that at any phase of health and development the two factors meet
to make total development a possibility in order to yield successful
results: (Figure III)
l.k Organization. It is said that one of the weakest links in
socio-economic development at the micro level is the failure to evolve pro
per organizational structures.
1.1 However defective the organization, some form of it could have
functioned if the principles of proper management were developed from the
grass-roots.
l.m The education of the masses and also of the management at the
micro level is, at best, at a very low level. The masses cannot grasp the
principles of organization and management, and help is not given to the com
mon man so that he could give supportive supervision in organizing and in
the management for economic growth. Usually the individual is not aware of
his basic human rights, and hence feels that whatever the organization of
fers, whether right or wrong, one has to merely accept philosophically and
has no participative role to play. However, when a person realizes, or he
is educated to know his rights, he starts looking at the management in a
more critical way. This person realizes that he pays taxes; he knows the
value of his vote; he knows what to expect of the management and the organ
izational structure, and if properly motivated, he is able to bring about a
change wherein he can at the micro level give support to the management to
implement their technology through a service or a programme.
l.n This technology has to be at a very basic level. However, bas
ic principles of technology from highly specialized areas can be adapted at
any level. Many times it has been noted that a doctor with a post graduate
degree of six years in a rural area is unable to apply his technology be
cause of organizational and management problems. In other words, he is not
given proper supervision; he has no support, and arrangements are not made
for him to have a sufficient budget or a technology is not available for
him to mobilise local resources. Rarely is he given an incentive to use
his ingenuity.
l.o This brings up factors of basic operational research. These is
a large amount of practical research (applied) in nutrition, organization,
management principles, health education, application of simple technology
which can be useful at the micro level to develop socio-economic growth.
l.p The health workers at this micro level can contribute to the
socio-economic growth of the area by participating in this basic research
387
so as to adapt local conditions of economics, health, etc., in the field of
health education, management and organization of health care services so
that this indigenous technology, when it is adapted and applied can utilize
the indigenous physical capital to the best advantage of the local popula
tion.
When an economic growth analysis is made of a development programme
all these above factors should be taken into consideration. In isolation
they will not produce the desired results.
l.q When analysing the health standard of a given area, knowledge
and attitude of a given population are extremely important. This has been
many times shown when a health model cost-effective analysis has been made.
The capital versus output ratio has shown that one should not over simpli
fy and isolate socio-economic policies with factors of development. Prob
ably one of the most important aspects that one has to consider at this
stage is the investment in man at the micro level.
In this investment the following four factors play an interacting
role with many ramifications:
l.r Policies at the national, state, district and also at the mirco
level and how these policies are implemented and interpreted.
l.s In other words, the directions these policies stress at the
micro level are extremely important. Very often the directives from the
district headquarters to the Block Development Office are not filtered down
in proper perspective and even if they are filtered down, they can be either
effectively blocked or can be misinterpreted, or misapplied due to two very
important factors: One being
l.t Political decisions and the other being
1.u the behaviour patterns of the local population.
However, if policies are good, if directions given are correct, if
the local population is involved in the decision making at the grass roots
level, which was so effectively demonstrated to the world by the Chinese,
then the political decisions will be consistent with the policies, and the
direction will be effective, so that the programme and its beneficial re
sults can filter down to the grass roots level. This grass roots evolution
of the policies and the consequent political decisions can give proper di
rection, which can then evolve into a behavioural change which will make
all programme implementation extremely effective for the total development
of a programme. Unfortunately, this type of involvement is not found in
the micro level planning in our country and even though we have Gram Sabhas,
Block Development Officers, and Primary Health Centres, due to policies
which are not in the best interests of the local community or political de
cisions which are favouring only a few, even though the direction may be
right, there is no behavioural change so that the investment in man does
not yield the desired results.
The dichotoniy between health programmes and general socio-economic
development probably will exist for many years to come (see Figure IV).
But still those who work at the micro level will find that this dichotomy
has to end or at some time a compromise has to be made. An analysis of the
coordination between government and voluntary organizations has been en
unciated by John Bryant (see Figure V) wherein he has shown that the Govern
ment seems to interact between its various social welfare programmes and
388
the Church organizations are isolated. In Figure VI he has shown how this
integration can take place. At the South East Asia Conference in Tokyo
(1970) another model was provided for micro level participation in develop
ment and health (Figure VII) wherein a minority church's role is shown as
an active presence for human and social development in all spheres of the
society. Here many factors which a governmental agency does not take into
consideration have been considered:
a)
Personal faith
b)
Supported by worshipping community
c)
Family faith
d)
Fellow Christians sharing in the task
e)
Neighbours who are good, bad, or indifferent
Probably this concept can be applied to any community or to many
communities who live together and of necessity their interests overlap in
the total development of the area. In diagram No. VIII the major factors
which control this development are shown as follows:
a)
Politics and the role of the government
b)
Religion and its diverse effects
c)
Socio-economic factors and the services that they produce
d)
Various types of education and media for recreation and leisure
In all these factors it must be noted that the individual and the
family have decisive roles to play without which effective development can
not take place. This is shown to be true not only in India but also in
other developing countries like Peru, and Bolivia. An analysis of the com
mon causes of death in a Catholic country like Peru showed that in the
males it was homicide. In children common causes of death were diarrhoea,
malnutrition and pneumonia. In women the common cause of death was abor
tion or suicide. Hence if development has to take place at the micro level,
general education has a very important part to play and health education
especially depends on the social milieu, and this education cannot take
place unless there are avenues for social reform. The late Dr. Ed. McGovran of the Ford Foundation mentions the "X" factor which is found mainly in
Voluntary Hospitals in India. This "X" factors seems to be absent in most
government health services.
III.
Health Development and Population Growth
Development at the micro level cannot take place unless there is re
duction in the fertility rate. To say that resources are available to take
care of high fertility rates is a most impractical statement. Twenty years
ago when this aspect was mooted, economists noted that this produced a di
lemma for as population growth increases the health care services propor
tionately diminish causing lack of development in the particular area. If
social numerator and rapid population denominator can be plotted on a graph,
it will be noted that population growth has to be checked (see Figure IX).
From the graph it will be noted that if the social numerator is 25, the
population denominator cannot be more than 5. This simple graphic presen
tation is supported by demographic data that if birth rate is 3% the popu
lation doubles in 20 years; if it is 1.7% the population doubles in 41
years, and if it is 1.2% the population doubles in 60 years. Some demo
graphers hence advocate a zero population growth as in Japan and Romania.
However, it is not possible for the developing countries to attain this
target as children who will be mothers in the next 11 years are already
389
born. The Malthusian theory that we should expect high mortality due to
pestilence, war, and flood to control population is morally unacceptable.
From 1960 the mortality rates have reduced and this has occurred both in
adults and in children, but has produced the even more disastrous results
of rapidly increasing population. Hence it must be noted that programmes
reducing birth rate are not the total answer for improving the development
of a given area. Most developing countries launched major family planning
programmes and India is one of these countries which spent millions of
rupees through USAID, World Bank, SIDA, etc.
Dr. Karan Singh, Health Minister of India stated in Bucharest at
the 3rd World Population Conference (August 1974) that India sees Family
Planning programmes as a massive attack on poverty. But merely introduc
ing a family planning programme is not the answer as you can easily see
in Figure 10. There is a vicious circle of high fertility with large,
poorly spaced families, crowded in a home with a high infant mortality and
keeping up with this high mortality, the farmer expresses the need to have
many sons to take care of the farm or the weaver who would like to have
his own children to take care of his unit of work. This produces a pre
condition for high fertility and in order to a certain extent slow this
runaway population growth, two major programmes have to be introduced:
(see Figures 10 and 11)
1)
Basic health care with an emphasis on nutrition and preventive
medicine, health education, and family planning is necessary. In the rural
areas family planning has been a definite failure because basic health care
does not exist. No nutritional programmes are available. Nutrition sup
plements or nutrition education are not available. Hence the childhood or
infant mortality still is high and a family planning motivator is ineffec
tive. Target couples refuse family planning as there is no assurance that
their children will live. So the behavioural scientists came up with a
questionable hypothesis, but others consider a very practical suggestion
that if a family has to accept a small family norm the communities have to
be influenced for behavioural change. A large force of paraprofessionals
were then trained (many times inadequately) as motivators, and the pro
gramme did not produce adequate results.
2)
Our own experience shows that unless the factors of social and
economic development through agricultural and small scale industries are
introduced at the micro level, so that basic requirements of food, shelter,
clothing and education are available, the community and the family will not
accept family planning.
IV.
The Role of a Health Worker in Socio-economic Development
In Figure 12 the modern concept of supportive factors for family
planning services at the micro level is shown. It is clear that socio-eco
nomic development has to be part of ari integrated programme with preven
tive, promotive, curative, nutrition, and family planning services which
are necessary ingredients to produce the desired results. To provide this
type of services adequate indigenous man-power teams are necessary who can
work closely with the family. These workers will form an integrated team,
with their different expertise, in order to understand each other's roles.
For example, the traditional doctor should be able to use the indigenous
dai or paraprofessional workers. The indigenous menidcant or dai is the
first person the villager seeks for health care. Paraprofessionals can be
390
taught simple health techniques in six months time. The health team must
be formed into a well-knit unit so that they can work with not only the
family, but the agriculturists, teachers, social workers, opinion leaders,
engineers and experts in small scale industries. Unless this integration
takes place, it will be impossible to train a team to work at the block
level. Gandhiji gave the nation this concept which was an inspiration
from a hymn by John Henry Newman, "I do not seek the distant scene, one
step enough for me". This one step of a simple integrated programme,
which the local community can organize, manage, and implement, is neces
sary for the development of a truly self-sufficient indigenous programme.
Economists and econometrists are quick to blame health and family
planning workers that techniques of economics are not utilised by them in
programme planning and budgeting. But it is also true that economists have
given very little time and thought to health and family planning programmes
and health workers are not equipped to utilise the techniques of econo
mists. It is hoped that in future economists will actively assist health
programmes at the macro and micro levels.
V.
Social Justice and Health
Unfortunately when development takes place, factors of social in
justice come into play. In one survey we noted that when the Pradhan knew
that he would not be directly benefitted, he lost interest. However, the
local people gave a great deal of cooperation in the survey for they knew
that they will be directly benefitted economically by the programme. The
elite money lender also was disappointed by the development programme but
the local people continue to help and responded with the opinion leaders.
In other words, socio-economic development can break age old barriers but
to a certain extent can also irritate those with vested interests. The
rift between the have and the have nots can increase. Strangely enough,
when health care is given equally at the micro level to a population, es
pecially through their own resources, barriers can easily break and caste,
and creed will recede into the background. Probably the basic reason is
that medical or health care transcends all barriers of race, caste, reli
gion and status. This is inherent in the training of the health care work
er. To give an example, general ward patients and private room patients
have no hesitation in being together in the intensive care unit or in the
recovery room. Furthermore, even male and female patients can be taken
care of in a recovery room for it is clearly understood that here a sick
patient, whether male or female, will receive the best care possible and
actually this type of a service is requested by the community. Through the
years our experience has been that the general hospital which caters to a
secular society can cater to the total health needs of the community,
whereas a private hospital or a private practitioner has to cater to the
whims, fancies and prejudices of the elite. Furthermore, if the parapro
fessional workers can be trained from an indigenous community, these work
ers can break social barriers. Occasionally we have found the head of a
high caste village home, who refuses entry to one of our paraprofessional
workers, especially when this household knows that this paraprofessional
worker comes from a lower caste. When this occurs we take a rather serious
view of the situation, and explain to the head of the family that actually
he is harming himself, as he is denied of services to his own household.
We never force ourselves into such a home, but when the head of the house
391
realises that his children are denied immunization through home visits, or
health education, or domiciliary maternity services, because he has refused
our paraprofessional entry to his home, for obvious reasons he will start
having second thoughts. Many times we have found that when a member of his
family suddenly is taken ill, and then this very same outcaste attended to
this patient in a very sympathetic way, immediately this prejudiced head of
the house will realise that he made an error in barring this paraprofes
sional from giving him the services that he requires. These types of bar
riers are many times extremely easy to break. What is more difficult is to
give equitable services at all levels in a village area. It is a common
platitude that the very rich and the very poor do not get proper health
care. The very rich because they are many times exploited and they are un
able to utilise common services which are easily available. Usually they
have too much advice, too many consultations, too many x-rays (not knowing
the hazards of radiation) and they find that in spite of the fact that they
have financial resources they have been misguided. The very poor do not
get proper health care because of lack of resources to pay for simple mecicines, and also lack of knowledge on simple sanitation and basic health
care. Many times the prejudices are so strong that even when simple health
care is provided to them, free of cost, taboos and customs prevent them
from accepting what is right. To give an example of the first, we know of
a Dy. Collector who came to us with about 40 x-rays of his chest which were
taken to diagnose a crack in his rib, which was due to over-weight and di
abetes. He merely coughed and his rib gave way! All this person needed
was a good clinical examination and probably one cone view x-ray of the
rib. By taking 40 x-rays in the civil hospital, whose quota of x-rays is
probably 150 per year, this civil servant has denied 40 poor patients who
needed an x-ray to make a proper diagnosis. This is how the rich, the in
fluential and those in positions of authority misuse health care facilities
and resources.
Hence in order to be able to give equitable health care the system
should be at the grass roots level which can mobilise local resources,
which needs to be extremely simple, and very close to the home so that the
health care system will become an integral part of the everyday life of the
villager. Many times health clinics are developed far away from the vil
lages so that the villager is unable to reach the place, the health worker
cannot reach the village, transportation costs are very high and in many
areas it has been shown that the farther the clinic the fewer the number of
patients who will utilize it. In our own rural experience, both in the
public health services at Mursan and 5 other villages we have developed a
low cost health care system which caters for basic health care, nutrition,
maternal/chiId health and preventive medicine. Even a loop is inserted by
our Public Health nurse under a tree. A woman with bleeding who needs a
termination of her pregnancy can be taken to a two-bed unit if proper or
ganization and expertise is available. In other words, low cost health
care is not merely an anathema (and has proven to be practical) but a real
ity. Even less common conditions like dental health care can be given at
the rural level. The new dental alloy equipment can provide a new denture
at a cost of Rs. 50/- which in most cities will cost Rs. 1,000/-. This is
being investigated in the Methodist Hospital, at Jaisinghpura. Anaesthesia
at a two-bed hospital can be provided, without oxygen, by using an EMO
392
apparatus. Hence in our rural units we do sterilization operations, hys
terectomies, and many other obstetrics and gynecology procedures using very
simple inexpensive techniques. The delivery fee at Mursan clinic is still
Rs. 5/- (about 75 cents) and in the semi-urban clinics if this person ac
cepts a permanent or semi-permanent method of family planning it will cost
her only an overhead charge of Rs. 30/- (about 4 dollars and 40 cents). An
immunization programme can be set up purely through government resources as
small-pox vaccines, triple antigen, BCG and cholera biologies are available
through government sources. Typhoid vaccination will have to be bought.
Any institution which has curative services can support a simple community
health programme with rural resources. In our experience of the last 3
years at the CFC Hospital, Vrindaban, Methodist Hospital, Jaisinghpura, and
the Public Health Services, Mursan where we have chosen selected popula
tions of 37,000, 2,500, and 9,000 and in the 5 rural centres which have a
population of not more than 4,000 to 10,000, we have proven that this low
cost health care is a feasible programme. Through the CMAI and SI DA the
Methodist Hospital, Jaisinghpura has a programme which takes care of 2,500
people who are mostly refugees. Our patients accept intra-uterine contra
ceptive devices because of improved technology and this is true of immuni
sation with a jet gun. Nutrition supplement and a basic health care sys
tem have been initiated which the local population can support. However,
while we are confident, and to a certain extent satisfied with this begin
ning, we are immediately faced with a task that these very people are not
provided with basic amenities of life - adequate food, shelter, clothes,
and education and any amount of health care cannot improve the quality of
life unless it is integrated with general socio-economic development of
the area.
SUMMARY AND CONCLUSIONS
1) An attempt has been made to depict the role of health in the
socio-economic development of a rural area. All aspects could not be
covered, as this is a very extensive problem.
2) Those interested in the subject must study in-depth the princ
iples of "Area-wide Comprehensive Health Planning" (Figure 13).
a) Concept
b)
Investigation
i) Problems
needs and
scope
ii) Data gathering
surveys and research
c)
Synthesis
i) Compilation and tabulation of data
ii) Preliminary review, planning standards and data projec
tion
d)
Evaluation
i) Evaluation
ii) Alternate solutions and
conclusions
e)
Development: development of final solutions and detailed
planning
393
f)
Realisation: Implementation phase
g)
Operation
3)
This presentation has highlighted some factors of coordination,
planning, management and control of an integrated programme, and has sug
gested that without socio-economic development health programmes do not
produce the desired results.
BIBLIOGRAPHY
1.
Statistics of the Government of India Ministry of Health 1972 - 1974.
2.
Interaction of health and socio-economic development by W.H.O. Public
Health Publication (occasional paper No. 45).
3.
Health and the Developing World by John Bryant (Department of Interna
tional Medicine, Columbia University, New York, USA - 1970).
4.
Paediatric Priorities for developing countries by David Morley - Butter
worths - 1974.
5.
Proceedings of the South East Asia Christian Council (Workshop on Health
development and Population growth), Tokyo - 1970.
6.
Proceedings and Reports of the Christian Medical Commission of the
World Council of Churches (Contact) - 1973-1974, Geneva, Switzerland.
[This paper was to have been presented with slides to which the Figure num
bers in the body of this paper refer. For more information please contact
the author]
Dr. E.B. Sundaram, F.R.C.S.(C)
Director, NIRPHAD
W-17, Greater Kailash II
New Delhi - 110048
India
394
Before 1947, the year of Indian Independence, the rural
areas had teen almost ccmpletely neglected in so far as the development of
health or medical care was concerned, though the country’s population was
predominantly rural.
Tn 1946, the Health Survey and Develonment Committee
(popularly known as the Bhore Committee) submitted a health plan in two parts,
a short term plan covering two five year plans and a long term one covering
the set targets to be reached.
One of the most important recommendations
in the long term programme of the Bhore Committee, was that the District
Health Organisations would have as their smallest unit of administration,
the Primary Health Centre (PHC), which would normally serve an area with a
population of about 10,000 to BO,000 and have a hospital with 75 beds,
6 medical office s, 6 public health nurses and the requisite nursing and
para nodical staff for 75 beds.
Tatar on the Mudaliar Committee, appointed
in 1961, strongly supported the recommendations of the Bhore Committee
and evaluated progress made since 1146,
Primary Health Centres were started as part of a national
rural development scheme, called Community Programme in 1°5P with a very
modest staff in each centre, to form the nucleus of integrated health
services to cater to the need of about 60,000 population in a block.
are now approximately 5373 PIICs.
90,000 to 120,000 nearly.
There
Each Centre serves a population of
The annual amount now allowed for medicines
for each Centro ranges from 10,000 to Hs.12,000 and this has to take care of
the above mentioned population,
More recently a Master Plan ror rural health was chalked
out with a participation of principals of Medical College, eminent medical
educationists, representatives of various medical associations, the Medical.
Council of India and the Indian Council of Medical Pesearch and finally
approved in October 1071 by the Central Council of Health consisting of the
The eight schemes included in the
Master Plan are:-
1.
q
Provision of two doctors to everyPHC
2.
Provision of a basic health worker and an Auxiliary Nurse Midwife
(ANM) to every 10,000 population
3.
Upgrading of at least one out of "very five PHCs into a 25 bed hosnital
with a Junior Specialist each in Medicine, Surgery and Obstetrics,
w in addition to the two PHC Doctors. These Specialists will periodically
visit the surrounding four Ppga for providing specialist consultation
to patients referred to them by the PHCs.
'•
2
6AMGALORE-560 001
all the States and Union Territories.
'
L, Prevision of financial assistance according to an apnroved pattern
to voluntary agencies for setting up hospitals in rural areas.
5. Involvement of all the existing governmental and non-governmental
rural hospitals and disnensaries in preventive and premotive health
care in addition to curative medicine.
6. Extension of Pilot Mcbile-cum-Training-cum-Service Hosoital scheme
to all medical colleges with a view to orienting tho Medical, and
Nursing students to rural community medicines, to enable them to
work in rural areas and also to render cor.metent medical care to the mral peon!
near their hemes with the help of teachers from medical colleges who would
work in well equipped tented hospitals which would move from one camp to another
every three months.
7.
-
Inrnrowjrent of village sanitation and imnart’nt' health education in
nutrition, maternal and child care and family planning.
P. Organisation of special camps for cataract operations, vasectomy and
tubectomy.
In April 1975, a programme for immediate action in rural
areas was included in the Renort of the Group on Medical Education and sunnort
Manpower.
This was followed by the now policy of the present Government of
India regarding Health Care Delivery system and Medical Education, where "every
home in rural areas was to become its own health centre", by transfering simple h
health skills to the rseople themselves, through Health Education.
Tn this connection it is important to note that if
the Govt, of India during the "'ant few years has established many medical.'
colleges, it was with the sole purpose of providing rural health services,
as the bulk of our population of nearly RO? live in the rural areas.
Tn
1947, there was an admission capacity or less than 2,000 students in medical
colleges, and now there are 106 medical colleges with an admission capa-ity
of more than 13,000 per year. About 11,000 graduation are coming-out of
theso colleges every year.
The St John s Medical Col''ego has boon trying to
incomorate in their teaching urograwne, the rural dimension in a
significant way.
As the college hapnens to be situated at tho outskirts
of Bangalore, there is an ACTION GROUP area whlhh includes-many of the slums
lying around tho college and its hospital cannier.
Tn addition, Hural ^ealth
Centres at Uttarahally, Siluvepura and Mallur (Health Go nerative) have
been running since quite seme years. Recently in January 1°7R, the Govt.
of Karnataka has been pleased to allocate the PHC Dccinasandra in Bangalore
District, Anekal. Taluk, for purposes of training the Undergraduates, Tnstems
and the various para-modi cal. and health workers of St John's Medical Collage.
3
Fural
Development
Schemas
The Department of Fural Development, Ministry of Agriculture
and Irrigation, Govt, of India, has /riven guidelines.for intensive deva"’ ooment
of FlocVs under the programme for •‘Integrated Hural Development".
Special beneficiary oriented programmes like Small Farmers
Development Agency (SFDA), Marginal Farmers and Agricultural. Labourers
(NFAl), Drought Prone Areas Programmes (DPAP) and Demand Area Development
Programme (CATP) ar© covering nearly 3000 blocks of our country.
It is
now proposed to intensify rural dox’el.opment work in 2,000 blocks covered by
any one or more of these special nrogramr.es during the year 19W-79.
In addition to these 2,000 blocks, it is also nroposed
to take another oro blocl-s for INTENSIVE PT DCF TEVET PLANNING AND
DEVELOPMENT every year '"or a period of five years starting from the current
year 1r'7P.
In this process, 3500 blocks would he covered by the end of
the Sixth P^an neriod.
Tho main objective of all these Integrated Fural Development
Programmes in selected Blocks, is to nrcnd.de full employment an'4 a letter
standard of living through productive programmes within a definite time
frame and with sufficient emphasis on the weaker sections of society.
Tn the execution of programmes, the family is to be taken as the unit
ard the attainment of economic viability as the objective.
Primary Health
in
Care
Hural
Development
Areas
Health does not feature in any of the Schemes to be taken
up under the programme for intensive development blocks although Health
and Development are closely linked areas for the total dovel onm-'-nt of
a community.
Neither of them can ’ e tackled in isolation.
The planners may be of the view that the existing structure
of health services available at the block level (PHC Complex) for providing
primary health ear-"1 to the peode would be adequate as a support service
for their development programmes.
Since independence, we have made
substantial investments in rural areas but the health
people is till far from satisfactory.
tatus of our
Health service hithertn4'ore has
been basically a service "distributed" by a group of health professionals
to a community whose role was that of a passive recipient.
There has been
very little participation from the community in solving its own health
prohlems.
If the Integrated Rural Development Schemes are to succeed,
we must provide concurrently, a CCMPREHENSIVE HEALTH SERVICE SCHEME
particularly in the preventive, promotivo, curative and rehabilitative
fields so that the rural people, taking the Ftaily as a Unit, are in a
....A
positive state of health, to actively participate in all corinleraontary
d evelonment activitie s.
The health of the mother and child in the <\ilc-im around which
the health of the village turns.
a.
The priority areas to he tackled will include:
Antenatal, maternity and postnatal, care
b.
Family Planning
c.
Care of under-fivos including innuniration
d.
Prevention of malnutrition in children
e.
Health 'Education
f.
Errvi ronmental Sanitation
g.
Control of leprosy
h.
Prevention of blindness
i.
Control of tuberculosis
The health professionals in the Planning Body of any development scheme should
be adequately oriented and with experience of community development and rural
health problems.
Providing primary health care to the rural masses in-our
country is a gigantic task and both government and voluntary agencies need
to collaborate and cooperate to meet the situation.
The St John's Medical
College can, not only provide the technical assistance required for training
of doctors, para-medieals (including Community Health Workers) and research,
but it could also, through its Pirectorate of Rural Health Services end
Denratment of Community Medicine, deal with organisational aspects of rural healtl
service, in selected project areas of Ccmunity Development.
Any project which seriously tackles the village rural health
scheme, should else bo concerned about making more effective thoso specific
training programmes which are intended barically for rural health, like
courses of training for para-medical workers and doctors ( interns ) and lay
the req'iired stress on rural orientation, as they will bo mainly responsible
for delivering the goods. Through such training, service will also be provided
to the ennmunity.
The St John s Medical College and its Fural Health Services
Organisation/Denartment of Community Medicine, will be catalytic agent for the
starting of village rural health services, wherever it is feasible. Our Health
Component Scheme, described later, for the Integrated Rural Development of
Anekal Flock, envisages such an integrated approach.
There aro two areas to bo taken into consideration while
talking or rural health services. Ono is the delivery of the package of
rura" health services in the villages and the other consists in all that
goes into the formation of personnel and transport that will deliver this
package of health services.
5
Mobility anc supervision are essontial to run an effective service
particularly ir. rural. areas. This is unfortunately not possible or
is a serious lacuna, in the present set up of the PHC comnlex. The
Extension Team of St John’s Medical College to function in these
development schemes will play the role of a task force. to achieve
the objectives laid down.
It will be the aim of St John’s Medical
College to whole-heartedly cooperate with Government and other
agencies in achieving their goal,
for effective coordination it is
desirable that the Dean/Director of Fural Health Services/’rofessor
of Coffljunity Medicine/District Health and Family Welfare Officer,
are included in the Apex Body direrting the Block Development Scheme.
At a later stage (Phase IT or Phase TTT) it may bo
possible to tackle health problems, by trying now methods in pilot
projects. If these are successful, there might be a chance for multiplication
of such projects to the benefit of larger sections of the corraunity.
For instance, solf-supoorting rural health schemes could be organised
in selected areas byt
a.
tagging health services to existing cooperatives which are being
run effectively eg. sericulture, cooperative dairying and so on
b.
starting with services (through Government or other funding agency)
and evolving a health cooperative at a later date with ths help of
the community nerved
c.
Assistance from Pcnchayat
' Tn sane villages, the Panchayat and people may be interested, in
health services and are willing to contribute to a health fund
both vo1 untaril y and through services provided
d.
running health services with some assistance Fran the ractory
administration where labourers are fran villages. As small Scale
Industries are being set up in rural areas, no single industry
will be in a position to establish its own factory medical service.
A co-operative can serve the health needs of a grown of factories/
industries.
In all our peripheral health schemes in rural areas,
special consideration has to be shown and greater attention given,
to the worker sections of the canmunity, particularly Harijans, who for
many reasons are canoaratively neglected in the health coverage.
Kith a view to organise Primary Health Care delivery
in the intensive. Bloc! Level Planning and Development of Anekal Block,
it is contemplated that the entire Anekal Taluk bo taken over ter
organising the health care
nd training programmes.
Anekal banners t.o be one of the Taluk Hoad Quarters
of Bangalore District, situated about 22 miles from Bangalore. Tho
Head Quarters at Anekal is also the Hea<i Quarters for the Camaunity
Devel orient Block.
Tn this Block of Anekal there are ? PHCs. me
located at Anokal itself ccrnanding a population
7F,000 and another
located at Pomnasandra commanding a peculation of 72,000.
The total number
of villages included in the Taluk coming under the jurisdiction of both
these PHCs, works out to
including the team of An’*
kal.
A Health Component for ths Integrated Rural Bevdlopunnt - Anel-al (Appendix A).
SD/(Fa.ior General B Mahadevan PVSM AVSM FAM?)
Tirector of Fural Health Services
and Training Progranr.es
St John’s Medical College
Bangalore 560034
(Dr SV Fama Fao MBPS DPH MPH FFTPHH)
Professor & Hoad of the
Dept of Community Medicine
St John's Medical College
Bangalore 5^0014
APPENDIX - A
A HEALTH COMP'TENT FOP THE TFTEGEATET RURAL DmLCPmiT-ANEKAL
AREA : Anekal Taluk in Pangalore District with a population of 1,50,000
distributed over a town (Anekal) and 2S7 villages is chosen.
There are two Primary Health Centres (Govert. of India pattern)
already functioning in the area with the HCs at Anekal and
Donnnasandra, respectively.
The S.1MC, Bangalore., has taken over
PHC Donnnasandra for organization of rrimary Health Care Delivery
and Trnnlementstion of several training programmes (which includes
undergraduates, interns and other para medical workers).
It is now nronosed to include the PHC Anekal also for implementation
of the various ccnmunity health programmes. The entire Taluk
of Anekal will thus be the area where the Integrated Hural Develop
ment will be in operation with its Health Component when the project
is implemented.
STAFF; The oresent infrastructure at PHC Dommasandra and Anekal will continue
to function but with the following additional inputs (pattern of
Nelamangala PHC) for each PHC.
1.
Medical Officer of Health
1
2.
Seni or health Inspector
1
3.
Lady Health Visitor
1
4.
First Division Clerk
1
5.
Senior Laboratory Technician
1
6.
Second Division Clerk
1
7.
Cook
1
8.
Part time Engineer
1
SUPERVISION;
Assistant Director Rural/Associate Professor-1.
To effectively
supervise all the activities over the entire taluk of Anekal and
also health components of the Integrated Project, a senior Officer
with the designation of Asst. Director (Rural Health) would have
to be in position at SJMC.
He will work under the administrative
and Technical Control of Director of Rural. Health Services and
Training Programres/I’rofessor & Head of the Department of Community
Medicine, St.John's Medical College, Bangalore.
,2/-
: 2 :
TP A?'SPORT : Since it is envisaged to deliver the Primary Health Care
Community as near to their doors as possible and the transport
available at PHC, is fully engaged with the National Health
and other routine programmes, ono extra vehicle (Jeep station
wagon) at each PHC and one for the Director/Drofessor/Asst.
Director at S-IMC would be required.
A total of three Diesal
Jeep station Damons would meet the requirements.
PROGRAlfrES: The present, programmes will he intensified and the quality of
care improved.
Besides involving the interns and parameficals,
the specialists and other faculty members of the SJMC will he
participating at all levels.
The routine programmes would be:
1. Medical care.
2.
Comrunicable Diseases Control (immunisations)
3.
Environmental sanitation
4.
MCH 7 TP
5.
Nutrition
6.
School Health
7.
Health Education
8.
Vital statistics and Maintenance of records
9.
Training and Research
The interns and paramedicals wo>>ld ho stationed at HQs of the
two PHCs at Dommase.ndra and Anekal.
Besides these two places
there are various tynos of disnensnries catering to the needs
of the community in the Taluk.
These are Sarjapur, Attibela,
Banrerghatta, Jigani, Marsur.
Tn the phase I of the programme, interns could Im assigned to
these dispensaries which would form the centre for their community
health activity.
As resources become available, accomodation
for interns and clinic buildings could cone up and the coverage
and activities could increase to its maximum.potential.
A project renort (see Annexure T) prepared to cover the Deminaaandra
and Anekal areas is enclosed.
This report gives greater details
of objectives, Implementation Mechanics and Finances involved.
This is the total Project Renort Phase I o' the Health Component of
the TFT
rogramne including staffing pattern, Transport, Area
of Operation and Expenditure is placed at Annexure IT for
immediate Tnc"1 ementation .
/ annkxtjre -1/
RATO DFLTWY AND Tin? TMPT^MENTATION
ORGAN!SAXTON 0” PRINAFV
OF TNTHPNS TRAINING.
(tn ccmmuntty mfftctnr)
The Training programme for both Interns and Paramedical
envisages a large service element for delivery of Primary Health
Care to the Communities in the development areas.
SPEC PTC OBJECTIVES:
Rural experience should train the interns to become the
leader of the Health Team ccrrprising of various types of paramedical
personnel and which will provide service to the conmunity. It should
involve:
a)
Supervisory responsibilities -
Administrative & Techinical
Community based health activities,
b)
Organisation and implementation:
i)
Control of communicable diseases
(special emphasis on diseases like Th,
Leprosy)
ii)
iii)
Implementation of National Health Programmes
The Health Team will render comprehensive
health care to the community - curative,
promotive, preventive.
HEALTH PR(yfT'lWAL ACTIVITIES:
i)
ii)
Health Education
Nutritional rehabilitation and eduration especially vulnerable group
iii)
Importance of exercise, rest recreation
SPECIFIC PROTECTION:
i)
ii)
iii)
iv)
Immunisations (PCG, Smallpox, DPT and ORAL Polio)
Disinfection of water
Introduction of Sanitary Latrinos
(a) Supervision and guidance in the mid-day meal
Programme in Schools and implementati on of
Applied Nutrition programme - vitamin A
(b) Iron and Folic Acid tablets distribution
(c) Distribution of contraceptives
v)
Introduction of compost pits, soak-pits, etc.,
EARLY DIAGNOSIS ART? PROMPT TREATMENT:
i)
General medical, check up of all. population in the
development area once a year.
ii)
Detection, treatment and foil w-un of patients suffering.
from Tuberculosis, leprosy, Malaria, Filaria, Trachoma,
Smallpox, Diphtheria, Whooning Cough, Tetanus, etc.
iii)
Conduaticn of antenatal clinic, domiciliary Delivery,
Post-natal care and family planning advice
iv)
v)
Organising under 5 citric
School Health Programme
vi)
Organising Specialists Camp ««
whc1' necessary
: 2 :
a) Obstetrics & Gynaecology Camp
b) Paediatric Camp
c)
Tental Camp
d)
Fermatology Camp
e)
Ophthalmology or Eye Camp
f) ENT Camp
g) Camn for minor surgery, etc.
N.B:
Organised with the assistance of Specialists of
St. John's Medical College.
DISABILITY LIMITATION:
Organising full treatment and follow - up of cases in all
chronic diseases and diaabilities
PF.HABH.JTAT JO?’:
Survey for handicapped shall be conducted to know the nature
and magnitude of the problem. Such of those dependents who are suffering
from chronic defects, disabilities and diseases will be detected and
registered. Depending upon the individual merits of the case, further
action will be taken in consultation with respective specialists.
MECHANICS OP TMPT TMEmTION OF INTERNS TRAINING (VIPE MAP APP’TJDET) (Annexure III)
Place
Domnasandra
Anekal
Population
72,000
78,000
No. of centres
16
16
Approximate population
in each centre
4,500
5,000
No. of births per year
175-200
200-250
No. of families in each
centre
1,000
1,000
No. of deaths per year
80-100
100-120
Population of under 5 (15%)
700
800
0-14 years (40%)
2,000
2,400
PRCFOSAL:
At each of the 32 centres, where an ANM and multipurpose worker
located, two interns will be assigned the responsibility of community
health to look after the population of 5,000, Thus 32 x 2 = 64 interns could
be trained at a time. However this Wealth Scheme will be operated in
3 Phases extending over 3 years. In phase I only 7 spboentres with
dispensary facilities will be x taken. The remaining over the next 2 years.
These interns will be exnosed to the experience of community
medicine. This will be an integrated approach and. delivery of comprehensive
health care as envisaged earlier in this proposal.
3
At the outset, the interns will survey and collect base
line data'and onen family dossiers for all fbmilies under their
care (1000 arnroximately).
Besides daily attention to diagnosis and treatment of sick
persons that attend the centre the interns will be involved in general
medical check up of all members in the family, once a year.
The abnormalities detected will be noted, discussed and
dealt with either by the intern at his level or referred to appropriate
levels including Specialists. Periodical cairos involving specialists
of various disciplines will, be organised whenever needed.
AS A FnjTTHS;
Antenatal clinic (with the help of ARM, Health
visitor and faculty of the Penartment of Obst. ft
Gyrae assisted by ARM)
Pomiciliary delivery (lady Interns)
Post-natal care (with the help of ARM)
Family Planning advice and services
Under 5 clinic (with the help of AIM, MPW and
faculty of the Department of Paediatrics)
will be organised and the intern will pay particular attention to
premotivo and preventive services such as - Health Education,
Immunisation, etc.
The Intern will, use his initiative and motivate families
to introduce Sanitary latrines and Soak-nits, etc., with the assistance
of MPW & ARM.
He will also supervise and guide the MPW to disinfect
drinking water veils periodically.
The intern will also draw un priority felt needs of the
population in fields other than health. The need based multi-discinlinary
annroach would be attempted wherever the activities of other departments
could be coordinated (Education, Agriculture, Animal Husbandry, Community
Development Flock, etc.).
The entire PHC offers a wide field for Research and studies
to be undertaken by interns under the guidance of their faculty members.
FAC TITTIES ARP AW7TT~ITf, PEQUTPEPr
ACCCMMCP ATTOP;
1) At each of the sub-centre headquarters
accommodation for the interns will he required. One hall 12’ x 10'
with a small bath room and latrine would be needed. The structure
need not be nucca. A. dwarf wall of 4’ right around, cement flooring
and thatched roofing or tiles (on the pattern of Pant.ist Hospital ward)
would suffice. The entire structure may not cost more than about
Ps.5,000/- at each centre or 3” centres x 5,000 will cost RsJ 1,60,000
Alternatively, if in some centres, suit'.ble accommodation
is available, we can hire on monthly rental basis.
In order to start the programme Interns could be located
at Central places like, Dasunasandm, Attibele and Anekal (Annexure TT ft TH)
where accanmodation could bo available and the interns could travel on
their cycles between centre and village.
...4
T^iFNTTlJHRt Each student will have a cot and a chair
(64 cots aiy- 64 chairs), one table for two students (32 tablas).
Total cost will work out to: Rs.150 ner cot x 64 .. Rs. 9,600/Rs. RO ner chair x 64. Rs. 5,120/Rs.150 per table x 32. Rs. 4,800/One steel or wooe’enalmirah)
at Rs.500/- x 32
)
Rs.16,000/-
TOTAL :
Rs.35,520/-
Basides, the above, mattresses, pillows, utensils and
sundries may cost about Rs.1000/- ner centre, totalling to Rs.32,000/-
TFANSPOPT: Each intern will have to be supplied with a cycle for his
movement within the jurisdiction of the centre. 64 cycles at Rs.350/each, totalling Rs.22,400/- will be fequired.
Each of those 32 centres will have to be provided with drugs,
certain minor equipments, instruments, appliances, etc. The capital cost
may work out to Rs.3,000/- per centre on total F .96.000/- and recurrent
cost of Rs.200/- per month ner centre or Rs.2,400/- (less than 50 nn), for
Rs.2,400/- x 32 = Rs. 76,800/-. Provision will have to be made for offring
al? facilities ror Primary Health Oerrtm d care delivery.
A small library of reference books to each of these sub-centres
would be necessary, at a nominal, cost of Rs.700/- nor centre and the total.
cost will work out to Rs.22,400/-.
2 mini buses and 1 Jeen (Piesel) with 3 drive’s and necessary
prevision for fu«i , oil, lubricants, servicing, repair and replacements
will ha’-e to be detailed at PHO and one at the College for use of staff
(Fs.3,00,000/- for throe vehicles plus 15,000/- ner annum).
TEACHING:
Supervision and guidance by Gtaff:
The faculty mem1 era will have to nay at least ono visit every
week to one or two sub-centres and involve themselves in teaching supervision
and providing the necessary guidance in the day-to-day problems, in the field
of general medicine, obstetrics & Gynaecology, paediatrics, surgery, etc.
It would also be necessary for all fnuulty members to meet all interns at a
meeting once a week at the Headquarter of the Primary Health Centre, where all
matters containing to clinical, administrative and other matters are fully
thrashed out.
HRATOHARrtP PF -yr 32 SHPCEHTPES — PHCE DCirASAT-TRA fr AWAL:
AWAL
1. Porsmarandra
2. SarJapura
3. Neriga
4. Futharanahally
5. Ridaragunpe
6. Handenabally
7. Wuthanallur
8. Attibele
°. kajt Mayasandra
10. Pamasagara
H.Q.
6.4 Inn
9.6 km
9.6 km
22.4 km
16.0 km
6.4 km
16.0 km
22.4 km
9,6 km
Anebal Town
Anekal Town
Aneta? Town
Samandur
Venkanahally
Tndalvadi
Sidi-Hosakote
Hargaddo
Jigani
Regehally
DISTANCE FRO1 H.Q.
H.Q.
H.Q.
H.O.
9.6
4.8
6.4
3.1
8.4
10.8
15.0
rrrrj
OTSTANCE FRCF H.O.
?
nqi'A-’AtTFA
dcwa^tra
DISTANCE Wl 1T.Q,
11. Chandanura
12. Huskur
13. Bapmasandra
14. Mugalnr
15. Bikkanahosahally
16. Yadavanahally
12.8 k.m.
11.2 k.m.
12.0 k.m.
10.8 k.m.
18.0 k.m.
16.8 k.m.
AJTEKAI,
DTSTAT'CR FROM
Pannerghatta
Hul.imangala
Hennagara
Hebbagodi
Marsur
Karpur
16.8 km
19.2 kn
11.2 kn
14.4 km
8.0 km
4.8 km
PHASE IT & ITT
(2nd & 3rd year)
TOTAL
EXPRNDITURR
CAPITAL
1.3 Jeeps (station
wagons-diesel)
at Rs.75,000/-each
PHA^-E T
(1st Year)
2,25,000.00
2,25,000.00
2, Buildings
35,000.00
1,25,000.00
1,60,000.00
3. Furniture
11,840.00
23,680.00
35,520.00
4. Mattresses, utensils
etc.
10,666.00
21,334.00
32,000.00
5. Cycles
7,466.00
14,934.00
22,400.00
6. Equipment to sub-centres32,000.00
64,000.00
96,000.00
7. Library at Rs.700/per centre
14,934.00
22,4n0.00
7,466.00
3,93,320.00
RECURRENT:
1. Pay and allowances
including TA. DA etc.
a. Asst. Director/
Assoc Prof.
21,000.00
45,000.00
b. Clerk (U.D.)
6,000.00
12,900.00
18,900.00
c. Drivers - 3 yrs .Nox.14,400.00
30,960.00
45,360.00
66,000.00
2. Drugs
25,600.00
51,200.00
76,800.00
3. Library-
7,466.00
14,934.00
22,400.00
4. Stationery
3,000.00
5,000.00
8,000.00
5. P.O.L. Charges at
Rs.5,000/- per year
per vehicle
15,000.00
30,000.00
45,000.00
6. Electricity water etc,.
3,500.00
32,000.00
35,500.00
7. Contingencies
5,000.00
10,000.00
15,000.00
8. Printing forms and
dossiers
6,000.00
4,000.00
10,000.00
TOTAL:::
3,42,060.00
AbWKXUHE IT
PHASE - I
Augmenting the staff of PHC s at Dccimasandra and Ane^al on t! e pattern of
1.
Nelamangala PHO.
retails are furnished below (for each PHC-D omnia rand ra
and Aneta!):
1.
Medical Officer of Health
1
2.
Senior Health Inspector
1
3.
Lady Health Visitor
1
4.
Hirst Division Clerk
1
5.
Senior laboratory Technician
1
6.
Second Division Clerk
1
7.
Cook
S. Part time Engineer
1
1
This would he a. comritnont on the Government of Karnataka.
Supervisory and supporting staff (to bo located at the Department or
2.
Community Medicine SJMC, Bangalore).
a) Assistant Director Rural/Assoc. Professor 1
b) Clerk (U.D.)
3.
1
Transport
Diesel Teen Station Wagons
3
(expenditure on 2 & 3 woiild be a committed expenditure of the Development
Project).
Areas of Operation/Trai’-ing
4.
The Health Development Operation would initially start at the following
areas w^ere facilities of medical cure is already existing through
dispensaries.
Anebal PHC
i.
Anekal
ii.
I’ersur
iii.
Jigard
iv.
Bannerghatta
Dcmnasandra PHC
i.
Domna'-■and ra
ii.
Sarjanura
iii.
Attibele
Derosasendra and its sub-centres am already under the technical control of
St. John’s Medical College (Department of Community Medicine). It would be
necessary to place PHC Anekal and its sub-centres under similar technical
control oh St. John's Medical College.
EXPENDITURE
CAPITAL
PHASE T
ATTOXORE IT
(Contd. )
PHARE IT & TJT
TOTAL
1.3 Jeeps (station wagons
disei)at Rs.75,000/-each 2,25,000.00
2,25,000,00
2. Buildings
35,000.00
1,25,000.00
1,60,000.00
3. Furniture
11,240.00
23,600.00
35,520.00
4. Mattresses, utensils etc
10,666.00
21,334,00
32,000.00
5. Cycles
7,4^6.00
14,934.00
22,400.00
6, Equipment to sub-centres
32,000.00
64,000.00
96,000.00
7. library at Rs.700/- per
centre
7,466.00
14,934-00
22,400.00
5,93,320.00
RECURRENT
1. Pay and allowances in
cluding TA,PA, etc.
a. Asst. Director/Assoc.Prof. 21,000.00
45,000.00
66,000.00
b. Clerk (UD)
6,000.00
12,900.00
10,900.00
c. Driver - 3 nos.
14,400.00
30,960.00
45,360.00
2. Drugs
25,600.00
51,200.00
76,000.00
3. library
7,466.00
14,934.00
22,400.00
4. Stationery
3,000.00
5,000.00
0,000.00
5. P.O.L. charges at Rs.5,000/ner year per vehicle
15,000.00
30,000.00
45,000.00
6. Electricity water etc.
3,500.00
32,000.00
35,500.00
7« Contingencies
5,000.00
10,000.00
15,000.00
0. Printing forms and dossiers
6,000.00
4,000.00
10,000.00
TOTAL
:
3,42,960.00
]
h
7V
PRESERVATION OF EYE SIGHT PROJECT
AN EXPERIMENT IN PREVENTION OF BLINDNESS AT COMMUNITYLEVEL.
* DR. M.V. JOSEPH
INTRODUCTION
Preservation of Eye-sight Project is an experiment in prevention
of blindness through grass root measures using trained Village Level
Workers.
It is estimated that there are about 15 million blind people in
the world of whom 5.8 million are in India. About 50 percent of the
blind in India are said to lose their eye-sight from preventable
childhood illnesses like Vitamin-A deficiency, Trachoma, Measles and
other inflamatory diseases. In the context of the socio-economic and
cultural background of a developing country like India, blindness is
much more disastrous a handicap to people than it is in the more
developed countries where facilities for educating and rehabilitating
the blind are easily available. Hence, surveillance against blindness
and its prevention assume great importance in the Third World.
The Project, Preservation of Eye Sight, has three basic aspects
viz. 1) prevention of blindness, 2) preservation of eye sight and
5) rehabilitation of the incurably blind. Around a focal point of
preserving vision, the project emerges as an almost comprehensive
village health programme. The aspect of prevention of blindness
includes services such as immunisations against common diseases,
health and nutrition education, nutrition supplementation, personal &
enviommental hygiene and early treatment of eye ailments. The
x
preservation of vision covers visual screening and correction of
refractive errors, screening and corrective measures for cataract
and glaucoma, house-to-house detection of diabetes mellitus, and
vigilance against hypertension. The rehabilitation component of the
programme aims at making incurable blind persons less dependent on
their families by training them in trade and craft.
* Associate Director, Community Health and Development Projects,
M.G.D.M. Hospital Kangazha & Honorary Consultant in Child Health to
Christian Medical Association of India.
-2-
PEOPLE AND THE PROGRAMME.
The programme is being operated by the M.G.D.M. Hospital of the
Orthodox Malankara Church of India. The target areas are situated in
the rural hinterlands of Central Kerala. Typically, the population is
made up of small-scale farmers, and farm hands. The latter earn their
living by working in nearby rice-fields and rubber plantations. They
form a hetrogenous community with different religious groups living
side by side, each following its own religious customs. Nevertheless,
there is homogenety in their attitudes and practices in matters of
health.
The literacy rate is high and the people are generally receptive
to new thoughts and ideas. Over 90% of those above five years of age
are literate in this area. About 50% have primary and 40% have
secondary education. The sex differentials in the literacy status
are not so striking as would be expected in other parts of the Country.
The literacy rate for males is 93% and for females it is 87%. Age
and sex composition of the population is typical of a community in
which the fertility has started declining in the past decade,
mortality is moderate and migration prevalent to a small extent.
Children under 1? years constitute 35% of the total population while
those beyond 65 years number less than five percent. Adults and
middle-aged persons belonging to the working-age group (15-44 years)
constitute 60 percent. Dependency ratio, an estimate of economic
dependence of the population obtained from the age distribution is 65•
Two villages, Anikad and Kunnamthanam in Central Kerala, South India
with a population of 30,000 were covered in the first phase of one
year's duration. Kooropada, a third village with a population of
over 20,000 was taken in the second year, and the programme has just
commenced in a fourth village.
The concept of a Village Health Worker seemed strange to the
people. The role of the Health Workers and their task had to be
carefully explained. Once having understood the concept, the
community's reaction was positive and the response enthusiastic.
The project proposal was to recruit workers from the community. The
people helped in identifying suitable candidates from among
themselves, following guidelines given to them. Thus each community
was able to propose its own Health Worker. The scheme was that the
recruits work on a part-time basis; they do home-visiting, on a
door-to-door programme. They are not attached to any work centre
or healtn post. Eventually, a tiered system of operational strategy
viz. a door-to-door service by Billage Health Workers, with the
necessary back-up services at the base hospital was evolved.
As the programs got under way, community contacts wore
enlarged. Local persons with leadership were involved in the work.
They were drawn to a community forum for dialogue. These contact
persons meet periodically to review project activities and make
necessary suggestions. Through such meetings, community participation
in planning, implementing and monitoring the programme was ensured.
The contact groups helped to harness local resource for the running
of the programme.
£HE_VILLAGE_LEVEL_HEALTH_WORKERS_AND_THEIR_TRAINING.
For the training of the Village Level health Workers different
models were experimented. The training sesi ion lasted eight weeks
for the first batch of workers: but in the second batch, it was
possible to cut down the duration of the training by a few weeks by
adopting a more skill-oriented model, in which half of the training
period was spent in the field under the guidance of the senior worker.
For the third batch a fully 'Worker-to-worker' model, where the new
trainees 'Learn-by-doing' under the supervision of the senior worker,
was evolved. Under this scheme, the new trainee resides & works with
the senior worker in the field area until the necessary skills are
learned. This way, it was attempted to simplify the training process,
eliminating the need for formal trainers and training centres. It
was observed that the 3rd batch of trainees gained optimal knowledge
and adequate skills for their task.
During the first few months of work, the Village Level Health
Workers do data collection, health education, immunisations, and
Vit-A prophylaxis, and screening and treatment of common eye ailments.
In the next stage, services like, diabetes and hypertension screening
and nutrition supplementation are undertaken. Glaucoma screening
and screening of school children for eye ailments followed in the
subsequent period. Thus the workers are progressiveJ.y indnetp'-1 to
the full range of takks. As shown in Fig.I more than 30% of the
problems wore effectively dealt with by the workers, the base facility
being required mainly for surgical management. The Village Level
Health Workers meet at fortnightly intervals at the base hospital
for review, follow-up and continuing education. A field supervisor
organises and oversees the work of the Village Level Health Workers.
£ItQ&BAMME_DETAILS.
1.
Prevention of Vit-A deficiency.
Blindness due to deficiency of Vit-A is a serious public health
problem in India, and Kerala i'tate is included in thd belt of
endemicity for this deficienc;r. The Government programme of Vit-A
supplementation which was existing, was strengthened through this
work. The incidence of Vit-A deficiency was brought down greatly as
shown in Big.II. An intonsivo education on nutritive value of green
-4leafy vegetables was made and an attitudinal change was observed
among the villagers. The Village Level Health Workers encouraged
housewives to grow vegetables in their garden and helped them to
exchange seeds with their neighbour for greater variety.
2•
j2S_2£_EE2^ 2iE_2212E j® JS^lnutrition.
The workers identified children suffering from protein calorie
malnutrition by simple and inexpensive methods such as measurement
of mid-arm circumference and bangle test. Suspected cases were
weighed and nutrition supplements were given, periodic assessment
of weight-gain being made. Peanuts, which were roasted fepacked by
the workers were distributed as nutrition supplements. The food
supplements were given for short periods only mainly for demonstrating
to the mothers that such simple measures can improve the health of
their young children. Mothers of infants were also educated ton the
utilization of easily available weaning foods.
3.
Pi®®ase_Control.
Immunisations are offered as an ancillary service to make the
programme as comprehensive as possible, Near hundred percent
immunisation against diphtheria, tetanus, pertusis, and polio-myelitiF
has been achieved. Measles immunisation could not be undertaken
because of the non-availability of the vaccines, although it was
considered important to prevent measles and the complication of keratc
conjunctivitis commonly encountered in poorly nourished children.
An epidemiological survey has shown that whooping cough has been
eradicated from children in the age group of 3 months to 5 years
with only sporadic cases occuring in school-going children and in
infants less than 3 months old. Tetanus and diphtheria have not
been reported in the last one year and only one case of polio
myelitis has been reported from the target areas.
4• Early_detection_and_treatment_of_eye_disoases.
It is estimated that 15 million people in India have eye
ailments and many of them go blind. Studies have shown that the
average length of time between the onset of eye ailment and the
commencement of appropriate treatment is atleast eight to ten days.
This, is largely because of the non-availability of medical services
at hand and partially due to ignorance. Many of the cases are simple
inflamatory processes and post-traumatic infections which can be
treated by trained workers. In the project area, the services of
the Village Level Health Workers were well utilized by the community
and the statistics indicate reduction in morbidity from eye ailments.
A study of trachoma, a common eye disease has shown 50$ reduction.
The reduction is attributed to mass treatment through the net-work
of Village Level Health Workers and the improved occular hygiene
that resulted from the educative efforts made by them.
5.
House-to-house detection of cataract and glaucoma.
Men and women over 35 years are screened periodically for
cataract and glaucoma. Most cases of mature cataracts habe been
identified by the Village Level Health Workers and referred for
suggical treatment. Figs. Ill & IV show the incidence of cataract
(Mature and inmature) and glaucoma in a 1C1.000 population.
6.
Diabetes and hypertension screening.
A door-to-door survey for diabetes meljitus and hypo:, tension
war undertaken by the workers. Cases which were positive to urine
test for diabetes were called for a blood sugar test followed by
Treatment wherever necessary. The workers continue to follow up
the cases and offer treatment and guidance on diet. They also
monitor the vision of these patients periodically. Anti-hypertension
programme, however, has been restricted to identification of cases,
guidance on dietary management and encouragement to seek medical adv;...:
7- Vision screening fpr school-going children and treatment of
refractive errora'
All school-going children in the target community underwent
visual screening. Refraction and follow up services were offered.
Vision has been preserved in many children and adults by correction
of refractive errors. Fig.Ill shows the incidence of refractive
errors. Vision has been corrected in most cases of pressbiopics
which required correction. This has helped many men and women to
pursue their ovn trade such as tailoring, weaving, fibre work and
so on.
8. Blind Rehabilitation.
The rehabilitation of all the incurably blind in the community
attempted. Those that could be trained, wore taught ahalk-<na.kjnpas a cottage industry. In the target area, houses are far apart
and for the handicapped, the uneven terrain of hillocks and streamlets
is difficult to travers. Training was therefore imparted to the
blind individually, and in their own homes. The hazards and the
inconvenience of going to a training centre being eliminated,
greater co-operation and willingness to accept rehabilitative
education was forthcoming and every one of the dozen trainable blind
was taught chalk making. This craft, they are happily pursuing in
the f-imiliar surroundings and. the safety and warmth of their own
homes. The project continues to help procure raw materials and
market the finished product
PRESERVATION OF EYE SIGHT PROJECT
Assessment of Trainees
Total marks: £0
Part I - Multiple choice questions
- Marks
25
* Read the question very carefully
* There is only one correct answer.
* Put v/mark on the correct answer only.
* If you put more than one xx^no marks will be given.
Part II - Read the statement carefully. Please indicate whether
the given statement is false or true by marking
Wrong answer with carry — mark£.
(marks: 10)
Part III
-
Marks: 15
cXt) —
&V3 CA
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*
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fro
Part - I
Inflammation of the conjunctiva is known .as
(a phlycten
(b) pterygium
(c) conjunctivitis
(d) Blepharitis.
2.
Cornea has no
(a)
blood vessels
(b) epithelium
(d) all of the above
(c) nerves
(e) none of the above.
5. Treatment of conjunctivitis
(a)
(b)
local antibiotic ointment or drops
atropine
(c) (staining
(d) all of the above
(e) none of the above
4.
Normal vision
(a)
6/60
(b)
6/6
(c)
HM
(d) Light perception.
5.
Vision in mature cataract will be
(a)
6/6
(b) 6/24
Oved
(d) Inches 2 below
(c) 6/36
BAWGAl OHE-^60 001
1.
-2-
6.
Inflammation of the lacrimal sac is
(a)
(b) Keratitis
Dacryocystitis
(c) Abscess
(d) Scleritis.
7.
Normal distance for vision checking
(a)
8.
(b) 60 metres
16 metres
(d) 3 metres
(c) 6 metres
(e) None of the above
Fluid in the anterior chamber is known as
(a)
lacrimal fluid
(c) Vitreous
(b) Aqueous
(d) All of the above
9.
10.
An active ulcer-on staining will
appear green in colour
(a)
Take up the stain
(b)
(c)
flourisin dye is used
(d) all of the above are correct.
(e) none of the above is correct.
Ulcer's are caused by
(a)
Injuries
(b) by applying eye ointments
(c) by simple rubbing over the lids.
11.
(d)by heat.
Treatment of corneal ulcer is
(a)
atropine, antibiotics local & systemic
(b)
staining.
(c) scraping
(d) Irrigation
(e$ none of the above is correct.
12.
In Iridocyclitis pupils are
(a)
Fixed and dilated
(c)
Irregular and non reacting
(d)
none of the above is correct..
(
(b) Fixed regular
13- Treatment of irdocyclitis
(a)
(b)
(c)
(d)
Pilocarpine & antibiotic joint.
Atropine & antibiotic oint.
Steroid, antibiotic oint. & atropine
all of the above are correct..
14. T&e transparent part of the normal eye
(a) conjunctiva
(b) Cornea 5 lens
(c) sclera
(d) lids.
15. Outer most thick elastic firm layer of the eye ball
(a)
sclera
(b) lids
(c)'Retina
(d) cornea
16» Visual impulses from the retina go to the brain via the
(a)
Choroid
(b) Cornea
(c) Optic nerve
(d) All of the
above.
- 5 17. Natural protection of the eye ball is
by hands
(b) lids and lashes
(c) eye drops
(d) all of the above.
(a)
18. Normal intra-ocular tension is between
mm. Hg.
(a) 10 & 20 mm. Hg.
(b)
(c) 5 & 10 m. Hg.
(d) 0 & 5 mm. Hg.
20 & 25
19. In acute conjunctivitis there is
(a) Circum corneal congestion.
(b) Discharge and corneal ulcers.
(c) Palpebral congestion & discharge.
(d) all of the above
(e) none of the above.
20. Ophthalmic peonatorum is seen in
(a) A.dults
(c) babies
(b) young people
(d) all of the above
(e) none of the above.
21. Pannus is seen in
(b) Corneal ulcer
(d) all of the above
(a) Angular conjunctivitis
(c)Chronic conjunctivitis
(e) none of the above
22. Treatment of Trachoma
(a) Sulpha drops . & Terramycin oint.
(b) Surgery
(c) Terramycin oint. & steroid
(d) all of the above •
(e) none of the above.
A 25. Spring catarrh is caused by
(a) Bacteria
(b) injury
(d) all of the above
(c) virus
(e)none of the above
24. Treatment of pterygium
(a) Antibiotic
(b) Atropine
(d) none of the above.
(c) Surgery
25. Hypopyon is collection of
(a) Sterile pus in the anterior chamber.
(b) Sterile pus in the cornea
(c) Blood in the anterior chamber
(d) None of the above.
-4-
26.
In acute iritis there is
(a) Discharge & iritation
(b) Cirumcomeal congestion and. pain
(c) Sudden loss of vision
(d) all of the above.
27.
Action of Atropine is to
(b) Constrict the pupil
(d) all of the above.
(a) Dilate the pupil
(c) Reduce pain
28.
Treatnent of Blepharitis
(b) Antibiotics ointment to
the eye lids.
(d)none of the above.
(a) Steroid ointments.
(c) Surgery
29.
In congestine glaucoma there is
(a) Reduced movements of the eye ball.
(b)
(c)
(d)
30.
Swelling of the lids
Severe pain & redness
all of “the above.
Pupillary size1 in acute glaucoma
(a) normal size
(c) Large and oval
31.
(b) very small
(d) None of the above.
Treatnent of glaucoma is
(a) Antibiotics
(b) Atropine & Antibiotics.
(c) Pilocarpine & diamox
(d)none of the above.
32.
Pilocarpine drops is used to .
(a) Dilate the pupil
(c) Improve the vision.
(b) Constrict, the pupil
(d) None of the above.
33• Ectropion is
(a) Turning out of the eye lids
(b) Swelling of the lids
(c) Turning in of the lids
(d) None of the above.
34. Squint is
(a) Abnormal position of the eye ball
(b) Closing of the lids
Jc) Normal position of gaze.
(d) none of the above.
35- Bitot spots are seen in
(a) Acute dacryocystitis
(b) In Vitamin-B complex deficiency
(c) Vit-A deficiency
(d) All of the above
(e) No'ne of the above.
••
“5- .
i
36.
Blepharitis is
(a) Inflammation of the eye lashes'
(b) Inflammation of lid margine
(c) Inflammation of the lacrymal gland
(d) all of the above.
37.
Diabetes conpain of
(a) Weight gain
(b) Decreased appetite
(c) Increased thirst & frequency of urination
(d) None of the above.
38.
Hypertensive complain of
(a) Head-ache
(b) Giddiness
(c) All of the above
39.
(b) Black outs
(e) None of the above.
Triple vaccine or DDT is given to- protect against
(a) Diarrhoea
(b) Diphtheria, Pertusis & Tetanus
(c) Diarrhoea, Pertusis & Typhoid
(d) all of the above
40.
Clealiness is essential to avoid
(a) Bad smell
(b) Promotion of good health
(c) Tp appear clean & attractive
(d) all of the above.
41.
Myopia is
(a) Unable to see distant objects
(b) Able to see distant objects elearly
(c) Difficulty in near vision
(d^ None of the above.
42.
Presbyopia is
(a) Difficulty in reading mainly encountered after the age
of 40 years.
(b) School-going children.
(c) Unable to read books
(d) Unable to read tho boards at a distance
(e) none of the above
43.
The vitamin essential for the eye is
(a) Vitamin B-complex
(b) Vitamin A & D
(c) Vitamin 0
(d) Vitamin D
(e) None of the above
44.
Treatment of spring cataract.
(a) Antibiotics
(b) Steroids
(d)
all of the above.
(c) Pilocarpine
45.
Phlyctenular conjunctivitis is characterized by
(a) a snail raised nodule near the limbus
(b) follicles
(c) Pannus & corneal ulcer
(d) None of the above.
46.
Chalzion treatment is
(a) Surg-ical removal
($) Steroids
(c) Antibiotics
(d) All of the above.
47.
The Eye drop used for local anaesthesia
(a) Vannycetin
(b) .Sulphacetamide (c) Xylocaine
(d) Pilocarpine
48.
Checking of intraocular tension is doing by
(a) placing the Tonometer on the cornea
(b) On the conjunctiva
(c) On the closed upper lid
(d) None of the above
49.
Part of the conjunctiva beneath the lids
(a) Lacrimal
(b) Bulbar
(c) Palpebal
(d) None of the above.
50.
Number of muscles that help in the movement of the eye :ball
(a) 6
(b) 16
(c) 8
(d) None of the above
51• Limbus is the junction between
(a) Cornea & Conjunctiva
(b) Sclera & Iris
(c) Cornea & Sclera
(d) None of the above.
52. My aim in undergoing this cause is to
(a) Learn something of the eye
(b) To learn & Keep it to myself & feel happy about it.
$c) To learn & to help others
(d) All of the above.
55. This cause was
(q.) very profitable to me
(b) it was like any other learning
(c) I would prefer some more teaching
(d)
very practical & useful
-7-
Part - II
True or False
I.
A complete examination of the eyes consists of :
Acquity of vision, field of vision and colour vision
(True, False)
II.
In myopia the main symptom the patient complains of will
be blurring of distant vision
(True, False)
III.
In myopia or short sight - parallel rays come to focus in
front of the sensitive layer of the retina.
(True, False)
TV. Myopia is corrected by covers or plus lenses
(True, False)
V.
Bony orbit is round in^ shape & has 6 wall with two
opening for the optic nerve
(True, False)
¥1. Glaucoma is a condition where the intraocular pressure is
raised as a result of high B.P. & diabetes. (True, False)
VII.
Lons is Biconvex () transperent and focuses the light falling
into the eye on to the retina. (True, False)
VIII.
The conjunctiva is this layer which covers the cornea & the
sclera & gets reflected on to fornics upto the margin of
the lids
(True, False)
IX.
Senili cataract is that which occurs in men & women over
the age of 50 years, which is treated by surgical
removal
(True, False)
X.
The full form of
PESP is protect eye & save person
(True, False)
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V
VOLUNTARY HEALTH AGENCIES CELL - A RURAL HEALTH PROJECT.
Note;
This write up only pertains to such voluntary agencies
as are engaged in rural development that includes an
element of health care. They will be referred to as
Voluntary Health Agencies(VHAs).
INTRODUCTION:
Voluntary agencies are assuming increasing importance, both
at the National and International level. In the field of health
services, voluntary organisations have played a pioneering role.
This is so because of the much greater freedom they enjoy to
innovate and experiment. Some of the measures which are now an
accepted practice in Government programmes, such as Community Health
Workers and Balwadies, such measures were first tested and tried
by voluntary organisations. As Brockington^ has written in his
classic ’ World Health' " Both countries (USA and U.K.) used
voluntary effort for much of the pioneer work".
However, our universities and other academic institutions
of hi^ier learning have often stayed away from voluntary agencies.
This is unf ortunate. f On the one hand voluntary agencies are starved.
of trained manpower while on the other hand academic institutions run
the risk of isolation from the common man and his problems. Bringing
them together may catalyze new work of both high Quality and
immediate social relevance.^
The desirability of starting a dialogue between grass roots
voluntary organisations and academic institutions of higher learning
would generally be conceded. But it may be more difficult to devise
suitable modalities for joint work. Some experimentation may be
necessary here.
Concept of Integrated Rural Development:
Till recently, our plans for rural development have mostly
been in terms of sectoral planning (R.N.Haldipur)?
But now the
emphasis has shifted to the functional and spatial integration of
various activities for the formulation of area development plans
(L.K.Sen)? Today it would be difficult to find a rural development
plan which does not call itself integrated rural development plan.
The need for scientific micro-level planning sensitive to local
variations is now generally understood.
- 2 -
Health has to be viewed in the same broad context. The
overall socio-economic status of a community is the most important
determinant of its health. Further, what goes on in one sector
almost invariably brings about a change in another. As all -the
factors involved in health problems are inter-related (Gunnar Myrdal)^
it is more logical to have integrated area development plans, of which
health plan is one component(functional integration), than to have
isolated health plans. "Rationally, the health problem becomes
integrated in the general problem of planning for development"
(Myrdal)f This is something which we can attempt if we work closely
with voluntary organisations that are attempting integrated rural
development.
Thus integrated health can become a component of integrated
rural development plans, as indeed it should. "The integration of
health policy with economic development and -the building of health
services into strategies of overall development are now considered
valid concepts" (Ramalingaswami,V. and P.)\
Aims and Objectives;
The overall aim of this project is to bring together the
specialized skills of a large academic institutions(AIIMS) and the
field experience and community involvement of voluntary health
agencies to the mutual advantage of either. This will open up
diverse field practice areas for broad categories of health services
and of research.
General Objectives;
a)
b)
c)
To provide technical guidance to voluntary health agencies.
To carry out research in the field of rural health and health
services, and
To utilise the facilities for teaching purposes.
Specific Objectives;
are listed below. They can be broadly grouped
into research oriented objectives, service oriented objectives and
training oriented objectives. Naturally, the objectives overlap.
Research oriented objectives:
i)
To collect systematic information on voluntary health
agencies; and to prepare an inventory/directory of such
agencies.
....V-
-3 -
ii)
To carry out comparative studies of different
approaches to health care.
iii)
To study the economics of health care,such as cost
accounting and cost-effectiveness of different health
services and strategies.
iv)
To carry out or support research in areas such as
epidemiology and operational research.
v)
To test the usefulness of Appropriate technologies
in rural health work.
Service Oriented objectives;
vi) To organise an information service for th e voluntary
health agencies providing them information on:
The activities of oiher voluntary healih agencies;
Health Care;
Availability of facilities such as:
Training facilities for healih workers;
Consultancy services;
Funding of health programmes;
Conference and seminars.
( A News-letter may be started)
vii)
To offer the following consultancy services to
voluntary health agencies in order to help them
initiate or ectend their health efforts:
- Identification of major health problems;
- Micro-planning for health care;
- Evaluation;
- Information inputs for planning and evaluation
functions;
Selection and training ojjh ealth workers.
viii)
To organise meetings and seminars of voluntary health
agencies.
ix)
To utilize the available facilities for teaching
purposes.(Postgraduate students can be involved in
health surveys and in the actual planning of concrete
health services for different regions, as opposed to
merely theoretical exercises).
x)
To undertake publications concerning all the foregoing
Methodology of work:
Working with voluntary health agencies on a countrywide
basis can be a vast undertaking, well beyond the capacity of a Cell
...... V-
- 4 -
or even an Institute. There is nothing modest about our needs !
But if the work is worthwhile, it aught to be dene. Even a long
journey starts with one step(Chinese proverb).
Some suggestions;
1.
The Voluntary Health Agencies Cell should be a part of the
Centre for Community Medicine. A senior member of the faculty
can be asked to look after it.
2.
An Advisory Committee may be constituted under the Chairmanship
of the Director,AIIMSe Senior members of the Institute faculty
interested in rural health may be invited; also perhaps one or
two experts(for example Secretary,AVARD: Association of Volunta?
Agencies for Rural Development).
3.
Establishment of contacts with Voluntary health agencies by:
a)
b)
c)
d)
e)
4.
publishing a NEWSLETTER biannually to start with, may be mor .
often later. The Newsletter should contain information of
interest to voluntary health agencies as given under Object?
Xo.v.
The Cell Incharge attending meetings of voluntary health
agencies' workers.
The Cell Incharge becoming a member of certain associations
having direct contact with voluntary health agencies such £.?
AVARD, Gandhi Peace Foundation and certain Catholic
Associations etc.
The Cell should establish contacts with certain Government
Departments dealing wifi voluntary health agencies; (such as
Deptt.of Rural Development and Central Social Welfare Board
etc.)
The Cell should also establish contact with certain s ocial
science and other institutions that are interested in rural
work, such a s Delhi School of Social Work, National Insti tc, •
of Community Development, UNICEP, I.C.A.R., I.C.M.R. and
several others.
(Steps b,c,d ar.'le have already been taken)
Office and Records:
An Office should be established. It should, among other
things, maintain individual files on voluntary healih agencies. The
relevant information can be collected in several ways: such as by
mailed questionnaires, personal visits and from published or
unpublished records of several agencies(Central Social Welfare Boa.
is publishing a multivolume state-wise directory of all agencies
5/-
- 5 -
doing social work". UNICEF has published an Inventory of "Basic
services to children in India". AVARD andGandhi Smarak Nidhi have
published nationwide directories. Files are also maintained by
several other organisations such as OXFAM, Catholic Hospital
Association, CARE, Indo-German Social Service Society (IGSSS) and many
others. Most well established societies are registered with State
Governments under Societies Registration Act of 1860.
Indeed a
plethera of information of variable quality is available from a large
number of diverse sources. The Cell will have to sift and evaluate
such information before it can be used. One State-wise list of
voluntary health agencies has already been prepared, including the nam
of the contact person.
5.
Requests from Voluntary health agencies for assistance;
These should be processed according to a pre-set procedure.
The voluntary health agency should be screened first. If it is
decided to help the agency, it should be visited by the Cell Incharge,
for on-the-spot evaluation. After this visit, the Cell staff can hold
a meeting to finalise the strategy. Generally a detailed investigation
of the health problems of the area and of the facilities available,
will be required. It may be necessary to visit the field area
periodically.
In the preparation or execution of area health programmes,
Hie local or state health authorities must be involved— as our efforts
should be to supplement, and not supplant, the state health organisation
6.
Research;
Some of the routine activities of -the Cell can come within
the ambit of research. The Cell can start other research programmes
either individually or with the help of some Departments of the
Institute. Concurrence ofthe voluntary health agency would be a
necessary precondition. On the other hand, some types of community
studies may be easier to carry out because of ihe already existing
infra-structure and ihe community cooperation created, by the agency.
7.
Funding:
The A.I.I.M.S. is expected to provide the basic facilities
or seed money, to put the Cell on its feet.
...6/-
- 6 -
Many voluntary health agencies may be able to pay for the
expenses incurred by the Cell in order to help them---- such as
transportation, Secretarial or statistical assistance etc.
Although the Cell can be started on a shoe-string budget, its
cost will escalate quickly once its usefulness is established.
However, arranging for funds from Government or non-Govt. agencies
will not be difficult,if the Institute considers this desirable.
8.
Other Inputs?
They will depend on the work-load. A i-esearch officer and a
Statistician may be required within a year. A good Social Scientist
can be most useful. Further requirements will depend upon the
performance of the Cell. It can become a fairly large undertaking
if the Institute so desires.
Advantages of the Voluntary Health Agencies Cell.
The benefits of this project are not far to seek. Apart from
the advantages accruing to voluntary health Egencies, and the better
health services reaching the rural communities, the Cell will have t‘
following advantages for the Institute.
1.
It will provide the Centre for Community Medicine with details
insight into ihe actual health problems of the rural
communities at the grass-root level- in several parts of the
country.
2.
Several large field practice areas will become accessible for
study and research, especially O.R.
3.
Various project areas can become demonstration centres for
community health services. Such efforts are more likely to
succeed as they will be implemented through local voluntary
agencies that already possess a record of useful community
service and that can ensure effective community participation
the sine-qua-non for a successful community health programme..
4.
Several alternative strategies for health care can be tried
and their relative merits evaluated..
5.
The teaching potential of such work must not be lost sigjit of
Apart from the demonstration of effective community health
services the postgraduate students can be involved in all
important steps, including surveys to determine the health
profile of an area, planning of actual community healih servi'
training of health workers, etc. instead of doing theoretical
exercises.
- 7 6.
The Cell offers ihe unique opportunity of planning for
integrated rural development where the health plan has to
be devetailed into a general development plan, of which it is
an integral component. It also offers the possibility of
testing the hypothesis of Dr.Melanbaum(6), who thinks nutrition
and health programmes give a great boost to overall development.
7.
The Centre for Community Medicine will have the opportunity
to experiment with the training, especially in-service training
of community health workers and volunteers and para-medical
workersc
8.
In all general development plans, the use of appropriate
technology is an important item. Where the atmosphere is
conducive, the Centre for Community Medicine can experiment
with the usefulness and acceptability of certain appropriate
technologies for rural health. A list of such technologies
has already been attempted.
REFERENCES;
1.
2.
3.
4.
Brockmgton, P. "World Health".p.167, Penguin Books,London,1958.
Haldipur, R.N. "Integrated Area Planning: Concepts and Methods"
Poreward. Published by ^raining Division of Department of
Personnel, Cabinet Secretariat, New Delhi— 1972.
Sen L.K. ibid. p.3.
Myrdal,Gunnar " Asian Drama" Vol.3, pages 1617-8; Published by
Twentieth Century Pund.Allen Late the Penguin Press,London,1968.
5.
Ramalingaswami; V and P. "Health Service Prospects" p.196
published by the Lancet and the Nulfield Provincial Hospitals
Trust,London , 1 975.
6.
Melanbaum, W. "International Journal of Health Services,Vol.3,
N o. 2,1973.
On-going activities for Voluntary Health Agencies:
A certain amount of work in the field of voluntary health
has already been attempted. It involved:
1.
2.
3.
Preparation of a State-wise list of voluntary health agencies.
This list is constantly “being extended (Ref. Objective No.(i)
Collection of information on various appropriate technologies
for rural health work. ( Ref. Objective No.(v)
Paying visits to villages served by certain voluntary health
agencies in order to study the health profile of the area and the
existing health services. This was followed by preparation of
micro-plan for the health needs of the area. Collaborating VHAs
are given below. (Ref.Objective No.(vii) Population covered: 1 lab.
..8/-
- 8 4.
Planning and conduction of household surveys covering
demographic, socio-economicand health variables.
Ref. objective No.(vii)
Population covered: 15000
(Sample size: 5000)
5.
Involvement of Postgraduate students in surveys and health
planning. (Ref.Objective No.(ix).
6.
Attemps have been made to establish contacts by becoming a member
of institutions working closely with voluntary health agencies
namely AVARD and Gandhi Peace Foundation.
7.
Some voluntary work is being attempted through National Service
Scheme also.
Collaborating voluntary health agencies:
The type of help mentioned above has been provided to the VHAs
described below. They are all well known and well established
voluntary organisation working in the villages at grass-root level.
This effort was confined to a population of about 1 lakh because of
personal limitations; there is no dearth of interested VHAs.
1.
Vedchi Intensive Area Scheme(VIAS),Valod Taluka, Dlst.Surat.
Population covered: 52,000.
2.
Tagore Society Simulpur Project, Di st. 24-Rarganas(iJ.Bengal)
Population covered: 12,000.
5.
Gram Niyojan Kendra’s project in Block Manbazar,Dist.Purulia,
(V/.Bengal) Population covered: 17,000.
4.
Vivekananda Spva Sadan,Village Mandra,Dist.Hoo$ily(W .Bengal),
Population covered: 15,000.
GRAVIS (Reg.) It is a voluntary organisation based; in a large
village called Daula, Dist.Meerut (U.P.,). This is a rural project
that was initiated by the writer of this note in order to
,
(among other things) gain experience in integrated, rural development
. work. Health will be an integral part of the overall development
process. Therefore a multi-disciplinary approach ms been adopted
with the collaboration of workers belonging to Deli?i School of
Social Work, Pantnagar Agricultural University, G.k. U.P. Engine?-, rr
and Architects etc. Gandhi Peace Foundation has a'.po joined han.
and has contributed an experienced Social worker /iio is now
staying permanently in the village with’h'is family. •
5.
6.
AVARD - I am helping AVARD prepare a Community health
Programme for the Jayaprabha Hospital and Research Centre
coming up in-Patna in honour of. J.P.
VOLUNTARY HEALTH AGENCIES
Note:
CELL- A RURAL HEALTH PROJECT
This write up only pertains to such voluntary agencies
as are engaged in rural .development that includes an
element of health care. They will be referred to as
Voluntary Health Agencies(VHAs).
INTRODUCTION:
Voluntary agencies,are assuming increasing importance both at the
National and International level. In the field of health services,
voluntary organisations have played a pioneering role. This is so
because of the, much greater freedom' they enjoy to innovate and
experiment. Some of the measures which are now an accepted practice
in Govt, programmes, such as Community Health Workers and Balwadies,
such measures were first tested and tried by voluntary organisations.
As Brockington has written in his classic ’World Health’ "Both
countries(USA and UK) used voluntary effort for much of ’the pioneer
work".
However, our universities and other academic institutions of
hi^ier learning have often stayed away from voluntary agencies. This
is unfortunate. On the one hand voluntary agencies are starved of
trained manpower while on the other hand academic institutions run
the risk of isolation from the common nan and his problems. Bringing
them together may catalyze new work of both high quality and
immediate social relevance.
|
The desirability of starting a dialogue between -grass root ■
(voluntary organisations and academic institutions of higher learning
would generally be conceded. But it may be more difficult to devise
suitable modalities for joint work. Sone experimentation may be
^necessary here.
.Concept of Integrated Rural Development: Till recently, our plans
for rural development have mostly been interns of sectoral
planning(R.N.Haldipur,2). But now the emphasis has shifted to the
functional and spatial integration of various activities for the
formulation of area development plans(L.K.Sen.5) Today it would
be difficult to find a rural development plan which does not call
itself integrated rural development plan. The need for scientific
micro-level planning sensitive to local variations is now generally
understood.
Health has to be viewed in the same broad context. The overall
socio-economic status of a conriunity is the most important determinant
of its health. Further, what goes on in one sector almost invariably
brings about a change in anoiher. As all the factors involved in
41'i'al'tir’ pixSW^-jiyt cr-^el;; ted(Sunhd^ ’fy'rdafl-’-hl.) (,-' •' •itr^si.ftWSc
i’lb'gL.cdl telh-ave (^n^ggr^te^
l-fplaAodsaone gppppnpnjc(function'al^in'tegfe-Kfferiiy^-th&n’ tzorhayp-.-is^l'itcd
£~
S
s is
-' ■ souediidng.which
which two
-we :.can.
..can. atte!ipt if we’’wdi$‘ clr6^^^Mi^t^e^GJd^jj.ry
\:rting-intonated rural d^vcliopf^i'i^^
nir ^ppdSdffc'-cf nidi ich.. •; . .
Xcon^onent •<oi?uif?t>cgrr?€@d rural
^devclopuin^^i&nd, ar®' iddcgd j.4 j^i.p^jLd^ "The^ integrat'i oA’ Bx^frdSttth
r • jpplicy.--with , econeriic de.vclonnent and the building’ or h^a^fFsF&rvices
-XsJ7
' '
'
iiitu strategics.,, of overall devuiopfiont are now considered VEllid
■'■ ■■
■•..concepts" (Rai.aliijgaswa! ii ,'V urid'pi 5) " •'• ; '
Aines and- Objectives; ■The overallain of this project is to bring together the
•opecial-izedos'ki'llel''of a;,large- apade^iic . institution (A I IMS) and the
. field ’experience and c-oruiuiiity involverient of voluntary1 health
' agencies'rto ■-•the mutual advantage .of either. This will o^n up’diverse
field pff-.cticeaureas yf or- broad categories of health' serviced'and
research.
,C.
, .,
General Objectivest
■ .' -.- -,.
' “ '
-; ■'</> l . ■ :
. r, . - . . .. , _ .. r
'■■'■ ■■-'
;a.)?fTcs. provide-. technic al ^i’dahc^'^-o- Voluntary'h-oa'lthi-fgofipies,
b) To .carry out research in th'e; tidld of;‘rural , he^th,^^ ..health
services,' find ■•
A
'
fj
....
.. . ‘■'■-■‘i‘hti;ri;p..onp
. . . c) To utilize the fac-ilitics’ foratieaching. purposes.
"•■’■'
■''■'-• ■■■. .-2
'■’ J"i;i ■ -1
vSpecifi-c. objec.tjves: arc lis'ted- below; Th’ey-'can'ib.enbrpadly^grouped _
. ia-tovreseg.rch-.G>riented . ob jectivedJsdrvic^'’oriented, -otyj^g^i^us and w
training- oriented objectives."Na'tiliiatly-'bt'h;efoobjective^- oyprlap.
i...
' iRfebetrch ..oriented, objectives:
. i).. To collect systehat'ic' infOrrtition on voluntary, health
agencies; and. to . prepare ; an inventory/directory of such
agencies.
' ' '
ii) To carry out comparative studies' of different approaches
to health care.
iii)
To study "the. econonics; of lyealth care, such /is cost
accounting.and cost-effectiveness -of different health
■ . .. services find 'strategies.
' iv) .To carry out or support'research in ureas, -such ^.s-,
' ’’ ’epidemiology and 'operational ^research.
v)
To test the usefulness of-Appropriate Technologies in
- 1 -
Service Oriented objectives;
vi) To orc-xaise an information service for the Voluntary health
agencies providing then InfOTTvTfTon on:
The activities of other voluntary health agencies
Health Care
Availability of facilities such as:
Training facilities for health workers;
Consultancy services;
Funding of health programmes;
Conferences and' seminars.
( A news-letter ray be started)
vii)
To offer the following consultancy services to voluntary
health c gencies in order to he Id then initiate or extend
their health efforts:
- Identification of .major health problens;
- Micro-planning for health care;
- Evaluation;
- Information inputs for planning and evaluation
functions;
- Selection and training of health workers.
viii) To organise meetings and seminars of voluntary health agencies
’ ix) To utilize the available facilities for teaching purposes.
(Postgraduate students can be involved in health surveys and
in the actual planning of concrete health services for
different regions, as opposed to merely theoretical exerciser
x) To undertake publications concerning all the foregoing.
Methodology of work:
Working with voluntary health agencies on a countrywide basis
can be a vast undertaking, well beyond the capacity of a Cell, or
even an Institute. There is nothing modest about our needs ! But
if the work is worthwhile,it aufiit to be done. Even a long journey
starts with one stop(CB.inese rjeverb).
Sone suggestions:
The Voluntary Health Agencies cell should be a part of the Centre
for eu;iriunity i-Iedicine. A senior member of me faculty can be askc
to look after it.
2. An Advisory Con'.iittee ray be constituted under the Chairmanship
of the Director ,AII11S. Senior members of the Institute faculty
interested in rural health, nay bo invited; also perhaps one or tv
experts(for example Secretary of AVAKD-Association of Voluntary
Agencies for itural Development).
3. Establishment of contacts with Voluntary health Agencies by:
a) publishing a EEV/SLETTER biannually to start with, ;ay be
more often Later. The newsletter should contain informatics
of interest to voluntary health agencies as given under
Objective Eo.5.
b) The Cell Inchargo attending meetings of voluntary health
agencies’ workers.
1.
- 4 -
c) The 'Cell .inchbrge becoming a -somber- of certaih
associ.'.tions having direct contact with voluntary
health agencies such ns A YARD, Gandhi Peace Foundation
and certain Catholic associations,etc.
d) The cell should establish contacts with certain Govt.
Departments dealing with voluntary health agencies
(such as Dcmtt.of Rural Development and Cefltr il Social
Welfare Bo'rd etc.)
c) The Cell should also establish contacts with certain
social science and other institutions that are interes in rural work, such as Delhi School of Social Work,
National Institute of Community Development .UIIICEF,
C.A.R.,
I.
I.C.M.R., Ministry of Health and several other;
(Steps b,c,d and c h.wv already been taken)
4.Office and Records;
An Office should be established. It should,among other things,^
maintain individual files on voluntary health agencies. The
V
relevant inf oration can be collected in several ways; such as
by nailed questionnaires, personal visits, and from published
or unpublished records of several agencies(Central Social Welfar
Board is publishing a nultivolur.e state-wise directory of all
agencies doirq social work . UNICEF has published an Inventory
of " Basic services to children in India". AVARD and Gandhi
Snarak Nidhi have published nationwide directories. Files are
.
also maintained by several other organisations such as OXFAM,
1/HdI—~ Catholic Hospital Association, CARE, Indo-German Social Service
Society(IGSSS) and many others. Most well established societie
are registered with State Governments under Societies Re gist rut?.
Act c-f 1860.) Indeed a plethora of information of variable
quality is available from a large number of diverse sources.
The Cell will have to sift and evaluate such information before
it can be used. One State-wise list of voluntary health agencies
has already been prepared, includin-g the name of the contact
person(See Appendix No.II).
5• Requests frorq Voluntary Health Agencies for assistance;
6.
™
These should be processed according to a pre-set procedure..
The voluntary health agency should be screened first. If it is
decided to help the ' ency, it should be visited by the Cell
Incharge, f • r on-the-spot evaluation. After Hi is visit, the
Cell stuff can hole
meeting to finalise the strategy.
Generally a detailed invest!.'ration of the health problems of
the area, and of the facilities available, will be required.
It ray be necessary to visit the field area periodically.
In the preparation ;,r execution of :rca health programmes, the
locjil or state health 'obh’oritics must be involved-as our effoshould bo to supplement, and not supplant, the State health
organisation.
Research;
Some of the routine activities of 'die Cen cnn come within the
ambit of research. The Cell can start other research programmes
either individually or with the help of some Departments ofthc
Institute. Concurrence of the Voluntary Health J gency would be
a necessary precondition. On the other hand, some typos of
community studies nay be easier to carry out because of the
already cxist-in;" infra-structure and the community cooperati or
created by the agency.
5/-
- 5 -
The A.I.I.U.S. is expected to provide the basic facilities,
or seed money, to put the ^ell on its feet.
Many Voluntary health igencies nay be able to pay for the
expenses incurred by the Cell in order to help then - such
as Transporation, secretarial or statistical assistance etc.
Although ihe Cell can be started on a shoe-string budget, its
cost will escalate quickly once its usefulness is established.
However, arranging for funds from Govt.or non-Govt. agencies
will not be difficult,if the Institute considers this desirable.
8.
Other Inputs;
They will depend on the work-load. A research officer and a
Statistician "ay be required within a year. A good Social
Scientist can be most useful. Further requirements will depend
upon ihe performance of the Cell. It can become a fairly large
undertaking if tie Institute so desires.
Advantages of the Voluntary Health Agencies Cell:
The benefits of this project are not far to seek. Apart from
the advantages accruing to voluntary health agencies, and ihe better
health services reaching the rural coniiunities, the Cell will have the
following advantages for tie Institute:
1 . It will provide ihe Centre for Coiinunity Medicine with detailed.
insight into the actual health problems of the rural communities
at tie grass root level-in several parts of the country.
2.
Several large field practice areas will become accessible for
study and research, especially O.R.
3.
Various project areas can become demonstration centres for
community health services. Such efforts are more likely to succeed
as ihey will be inpler ented through local voluntary agencies that
already possess a record of useful community service and that can
ensure effective community participation, the sinc-qua-non for a
successful community health programme.
4.
Several alternative strategies for health care can be tried and
their relative merits evaluated.
5.
'The teaching potential of such work must not be lost sight of.
Apart from the demonstration of effective, community health services,
the postgraduate students can be involved in all important steps,
including surveys to determine the health.profile of an area,
planning of actual community health services,training of health
workers, etc. instead of doing theoretical exercises.
6.
The Cell offers the unique opportunity of planning for integrated
rural development where the health plan has to be dovetailed into
a general development plan,of which it is an integral component.
It also offers the possibility of testing the hypothesis of
Dr.Melanbaun(5), who thinks nutrition and health programmes give
a great boost to overall development.
....6/-
- 6 -
7.
The Centre for COnriunity 'iedicine will have ihc opportunity
to experiment with ihc training, especially in-service training
of co "’.unity health workers and volunteers and pare.-tie die d i
workers.
8.
In all general development pions, theuse of appropriate
technology is on inportant item. Where the atnosphcrc is
conducive, the Centre for Conaunity Medicine.can experiment with
the usefulness ^nd acceptability of certain- appropriate
technologies for rural health. Alist of such technologies has
already been attempted (Appendix II)
BEFEREli CES:
1.
2.
Brockmgton, F."World Wealth". p.167.Penguin Books,London,1958.
.Haldipur, R.i . "Intcj-roted area planning: Concepts and Methods"
-J'orewardPublishcd by Training Division of Department of Personnel,
Cabinet Secretariat, Dew Delhi - 1972.
3.
4.
Sen L.K. ibid. P.3, ■
■
Myrdal, Gunnar "Asian Drand" Vol.3,pages 1617-8; Published by
Twentieth Century Fund. Allen Late the.Penguin Pre ss, Lend on, 1968^
Ramalingaswani; V and P."Health Service Prospects" p.196
Published by the Lancet and the I'ulfield Provincial Hospitals
Trust.London, 1973.
6. Me'lanbaun, W."International Journal of Health Services, Vol.3,
• To.2,,1973.
5.
APPEIWIX- I
On-going activities for Voluntary Health Agencies;
A certain amount of work in the field of voluntary health
agencies has already been attempted. It involved:
1. Preparation of a State-wise list of voluntary health "gencies.
This list is constantly being extended.
Ref. Objective Ilo.(1)
?
Also see Appendix II. '
.
2.
Collection of information on various-appropriate technologies
for rural health work.
Ref. ob jactive li o. (v )
See Appendix III •
?
Paying visits to villages served by certain voluntary'health
agencies in order to study the health profile of the area and the
existing health services. This was followed by preparation of
nicro-plan for the health needs of the area.Collaborating VHas are
given
Ref. Objective lio.(vii)
T o ta1 p o pulat i on c ov ere d: 1 lakh.
4. Planning and conduction of household surveys covering demographic,
socio-economic and health variables.
Ref.objective Ilo.(vii)
Population covered: 15000
(sample- size:
5,000)
5. Involvement of Postgraduate students in surveys and health
planning. Ref.objective No.(ix)
6. Attempts have been ’.vule to establish contacts
by be coring a
p.oriber of institutions working closely with voluntary health agenc-’
namely AVARD and Gandhi Peace Foundation.
7. Some voluntary work is be 3 n,- attempted throufh National Service
Scheme also.
Collaboritin, • voluntary health agencies: .
The type of help mentioned above has been provided to the VHAs
described below. They are all well known and well est -.blished
voluntary organisations working in. the villages at grass-root level.
This effort was confined, to
population of about 1 lakh because of
personal limitations; there is no dearth of interested VHAs.
1. Vedchhi Intensive area Scheme(VL-S) ,Valod ialukb,Hist-.-Surat,
Population covered: 52,000.
2. Tagore Societys’ Sinulpur Proj'ect,Rist 24-ldargnas_(W.Bengal)
Population covered: 12
*,000
■ ■
3. Gr.iii iliyojan Kendra's project in Block Hanbazar,_Dist.Purulia,
(WlBengnl) Population. covered: 17,0.00.
4. Vivekananda. Seva Sadan,Village ab.ndra,Bist.Hoo/hly(W.Bengal)
Populati on covered:15,000.
5. GRaVIS (Reg) It is a voluntary organisation based in | large villa.-'
called ^aula,Rist.Ueerut(U.P.) This is a rural-'project that was
initiated by the Writer of thisnote in order to(anong other things'
gain experience in integrated rural development work.Health will
be an integral- part of the overall development process.Therefore a.
multidisciplinary approach has been adopted,with the collmburatior
of workers belonging to Delhi School of Socio 1 Work, Pantnagar
Agricultural University,G.R.U.P.Engineers and Architects etc.
Gandhi Pence Foundation has also joined hands and has contributed
an experienced Soci.il Worker who is now staying permanently in the
village with this frilly. a detailed report on GRAVIS is attached
as Appendix IV.
3.
APPENDIX
I
On-going activities f.....
or Voluntary Health Agencies:
A certain amount of work in the field of voluntary health
agencies has already been attempted. It involved:
1. Preparation of a State-wise list of voluntary health •gencies.
This list is constantly being extended.
Ref. Objective I)o.(1 )
Also see appendix II.
2.
Collection of infer"’.tian on various appropriate technologies
for rural health work.
Ref. ob j.cctivc I-i o. (v)
See Appendix III
Paying visits to villages served by certain voluntary health
agencies in order to study the health profile of the area and the
existing health services. This was followed by preparation of
micro-plan for the health needs of the area.Collaborating Vitas are
given .
Ref. Objective iio.(vii)
Total population covered: 1 lakh.
4. Planning and conduction of household surveys covering demographic,
socio-econonic and health variables.
Ref. objective Ho.(vii) '
\ Population covered: 15000
(sample size:
5,000)
5. Involvement of Postgraduate students in surveys .and'health
■ planning. Ref. ob je ctive N o. ( ix.)
6. Attempts have been ■■ade to establish contacts and by becoming a
member of institutions working closely with voluntary health agenc‘
namely AVAltD and Gandhi Pe-.cc Foundation.
7. Some voluntary work is beta/ attempted through National Service
Scheme also.
Coll..bar itin, ■ voluntary health agencies:
The type of help mentioned above has been provided to the VHAs
described below. They arc all well known and well established
voluntary organisations working in the villages at ,-rass-root level.
This effort whs confined to
population of about 1 lakh because of
personal limitations; there is no dearth of interested. VHAs,
1. Vedchhi Intensive .-.ra-a Sche'ie(VL-.S) ,Valod &aluka,Dist.Surat,
Population covered: 52,000.
2. Tagore Societys’ Simulpur Project,Diet 24-Pargnas(W .Bengal)
Populati on covered: 12,000
3. Gran IJiyojan Kendra’s project in Block Hanbazar,D'ist.Purulia,
(W.Bengal) , Population covered: 17,000.
4. Vivekananda Seva Badon, Villa pc hndra,Dist.Hoo>-hly(U.Bengal)
Population covered: 15,000.
5. GRaVIS(Reg) It is a voluntary organisation based in a large villa/?
called -o.au1 i,Dist.'.Iecrut(U.P.) This is a rural project that was
initiated by the writer of thisnotc in order to(anon-- other things
gain experience in integrated rural development work.Health will
be an integral port of the overall development process.Therefore multidisciplinary approach has been adopted,with the collabcratic;
of workers belonging to Delhi School of Social Work, Pontnafpar
Agricultural University ,G.R.U.P .Engineers and Architects etc.
Gandhi Pc: co Foundation has also joined hands and has contributed
an experienced Social Worker who is now staying permanently in th‘
village with this family. A detailed report on GRAVIS is attached
as Appendix IV.
3.
h •
HEALTH CO-OPBRATIVE - A NEW STRATEGY IN THE DELIVERY
OF COMPREHENSIVE HEALTH CARE - AN EXPERIMENT AT MALLUR
INTRODUCTION
Health facilities in rural areas in the country were provided
through Primary Health Centres started as part of a national rural
development scheme called 'Community Programmes' in 1952, with a very
modest staff in each centre to form the nucleus of integrated health
services and cater to the need of about 60,000 population in a Block.
There are now over 5,200 Primary Health Centres, each Centre serving
a population of 80,000 to 120,000.
For establishing an effective and viable Primary Health Care
system, the co-operation of the local community must be ensured. In
fact,, the people should be adequately motivated, involved in decision
making and actively participate in health programmes, so that ultimately
it becomes their own "peoples programme". Local resources such as
co-operatives, agriculture, manpower, buildings and most important of
all local leadership, should be used to solve and finance the local
health programmes. It is desirable that the Primary Health Care system
should be a self-sufficient fiscal entity. Community priorities are
more likely to bo met if the people themselves raise and spend the
resources required. A "Total health" approach is essential. Promotional,
Preventive and Curative care need to bo completely integrated.
THE MALLUR MILK CO-OPERATIVE (MMC)
Mallur is a village in Kolar District of Karnataka, situated
35 miles from the city of Bangalore. The Mallur Milk Cooperative (MMC)
was an established concern with a- so.and and progressive leadership
and had been functioning for many years. In addition,to production
and sale of milk, it provided other benefits like provision of
fodder and cattle foods, tractor facilities and looms at low rates
of interest.
Besides the people of Mallur, two other villages, Muthur
and Kachahalli were members of the Co-operative and the total
population covered was about 3,000. These villages had a silk farm
co-operative besides cooperative dairying. The economic position was
satisfactory, and, therefore, all conditions were favourable for
the introduction of other self-supporting schemes.
The inspiration for establishment of a Comprehensive Health
Caro Progranme for the Cooperative Members and their families of these
villages, came from Sr Anne Cummins of Coordiniting Agency for
Health planning (CAHP) and Fr Jonas of the Catholic Bishops Conference
of India (CBCl). With thtjse pioneers, the Dean and the Department of
Preventive and Social Medicine of St John's Medical College,
representatives of the Karnataka Government and Bangalore Government
Dairy with loaders of the Mallur Milk Cooperative, worked out a scheme
for tagging on a health service to the existing MMC.
The main objectives of the Mallur Heilth Project were:
(a)
to study and devise methods by which the financial
base needed for effective health services could emerge
from tho people themselves in a self-sustaining manner;
2
(b)
to help in the establishment of rural health
centres with the staff and rendering of effective
health services to a wide circle of needy peopld
without distinction of race, caste or creed;
(c)
to study the required strategy and methodology for
the effective rendering of primary health care
in rural areas by trying to determine the priority
areas in health care and devising the structure found
suitable to village conditions;
(d)
to help in those developmental activities which are
very necessary to ensure effective rendering of
health services in rural areas; and
(e)
to train intern doctors, nurses and other medical
and para-medical staff for the purpose of rendering
assistance in rural areas.
The St John's Medical College and its Department of
Preventive and Social Medicine were to be mainly
concerned in acting as a catalytic agency, in the
formation of a self-sustaining rural conuaunity
health scheme, fulfilling the above objectives.
It was estimated that a monthly budget of Rs.2,500-3,000/would be required for running the Health Cooperative and financial
support was forthcoming by a joint contribution of 3 paise per litre from the
MMC and Bangalore Dairy, in a phased formula as shown in Table I below.
Ultimately the MMC was to completely finance the scheme.
Table I (Contributions to the Health Co-operative)
Contributions/litre
Year Milk Co-operative
Bangalore
1st
1 P-..
2 p.
2nd
2 p.
1 p.
3rd
3 P-
nil
Dairy
This budget was adequate to support a health programme,
organised by a Medical .Officer,' Nurse, Compounder and an Ayah. The
staff were appointed by the Health Co-oporative Committee.
The Health Co-operative Committee included the
followiig members:
Chairman, MMC
Secretary, MMC
Dean, St John's Medical College, Bangalore
Head of the Dopt of Preventive and Social Medicine,
St John's Medical College, Bangalore
Director/General Manager, Bangalore Dairy
Representative of State Health Service
Medical Officer, Mallur Health Cooperative (Secretary)
The composition ensured integrated.planning between the MMC and Health
Co-operative.
:3:
The Ho .11 th Cooperative got off to a good start by being
inaugurated on 19 March 1973 by tho Minister of Animal Husbandry.
Dr VK Rajkunar, a Senior House Officer in St Martha's Hospital,
joined as Resident Medical Officer in charge of the Co-operative.
The Health Cooperative, in November 1973> was joined by
another dedicated worker, Maria, an Italian Public Health Nurse.
She with her companion Cathy, a Volunteer from Canada, looked
after the Maternal and Child Health Work.
Within five months of starting the project- (August 1973),
the cost of fodder went up and milk production of the Milk Cooperative
fell as some members began to sell out on higher rates. The MMC
took a decision, much to the discomfiture of the Government Dairy
Authorities, to sell directly to private parties in Bangalore, who
offered better prices. The Government Dairy, therefore, stopped its
contribution of 2 paise per litre as health subsidy, and the Health
Co-operative was in a critical situation. It is at this stage, a
momentous decision was taken by tho responsible village leaders who
were more than convinced of the positive role of .the Health Centre
and its staff in improving the health status of the people in Mallur
and other villages. The Milk Cooperative was doing well and decided
to contribute 5 paise per litre for health and took over financial
responsibility for running the Health Centre. This financial
strategy on the part of village loaders resulted in the Project
becoming a-viable unit. The Milk Cooperative has borne the entire
recurring costs of the health project ever since. Receipts/Payments
position for the period 1975-76 is appended (Table II).
Although the Mallur Health Project is mainly financed
by the Mallur Milk Cooperative, it also receives help and technical
direction from St John's Medical College and the Government Health
Service. These inputs are shown in Table III.
Table III
Source
_______ Capital___________ ___________ Recurring____________
1. Mallur
Milk
Cooperative
Buildings, Furniture,
Refrigerator, Health
Education Materials
Salaries, Rents/Electricity,
Drugs,,General Stores, Petrol
2. St. John's
Medical
College
Physicians and
Midwifery Kit, Minor
Surgical Equipment,
Lab Equipment
Motor Cycle (on loan
through UNICEF)
Interns services
Specialist Services
Rent and electrical charges
for interns quarters
3. Government
Health
Service
Nil
Vaccines, Vit. A., Iron,
Folic acid supplementary
FP Devices, Surveillance of
Communicable Diseases (through
PHC Sidlaghatta) Health Educa
tion Films (through Health
Education Departmentof DHS)
4
SERVICES R3NDER-SD THROUGH COMMUNITY PARTICIPATION
The St John's Medical College adopted, this Health Cooperative
as a rural training centre for interns. Visits by specialists of other
departments including specialist camps were organized. At present,
4 interns are attached at any one time for whom residential accommodation
has been provided by the MMC on a rental basis. The interns conduct
base line demographic surveys, immunization and school health programmes,
special health projects and mass health education programmes.
The Health Cooperative Committee meets at Mallur periodically
to discuss progress and plan for the future.
Dr Rajkumar after a dedicated service of nearly 4 years
resigned from his post and Dr Kiriti Keshavan has taken over from
15 June 1977.
The Health Team comprising of Dr Kiriti, his staff and
interns under the technical supervision of Department of Preventive
and Social Medicine, St John's Medical College, has made good contact
with the villagers and a comprehensive health care programme has been
introduced. The community of Mallur and other member villages actively
participate in all programme. They have no unreasonable expectations
or demands, as the health project is their own programme brought
about through their own contributions. This is a basic difference
between Health Centre organised through Cooperatives and Governmental
Agencies. The leaders are actively involved in the planning and
organization as the Chairman, MMC is the Chairman of the Health
Cooperative Committee and tho Secretary, MMC’its member. Paramedical
workers are drawn from the village community and trained for Community
Health work. The Ynung Farmers Association actively assists in any
of the health programmes. They help interns in their survey-; programmes
of immunizations and environmental sanitation including chlorination
of wells and construction of sanitary latrines. They also organise the
physical arrangements for the Mass Health Education Programmes. The
Mahila Mandal runs a nursery school and acts as a forum where health
education, applied nutrition programmes are undertaken.
The Health Team and interns organise the following services
with community participation.
PERSONAL SERVICES
1.
2.
Curative Clinic (daily out-patients)
Maternity and Child Health Services:
i. antental care; ii. midwifery (domiciliary)
iii. postnatal care;iv. under five clinics (domiciliary)
5.
School health services for village schools
4. Immunization programmes for smallpox, triple antigen,
tetanus toxoid, BCG, typhoid and oral polio
5. TB and Leprosy case detection, treatment and follow up.
6.
Motivation for family planning
7.
Specialist Camps at Mallur (monthly visits by Specialists
from St Martha’s Hospital, Bangalore)
8.
Hospital Referrals
9.
Family record maintenance
5
:5:
community sshvicss
1. Protection of well water by chlorination
2. Popularisation and construction of sanitary latrines
and soakago pits and other advise on environmental
sanitation
3. Collection of health data through periodical surveys
4. Coordination and cooperation with government- health
personnel in National Health Programme activities
5. Health education at personal, group and village levels
6. Nutrition education and nutrition supplementation
programmes
Members of the Milk Cooperative and their.families are
entitled to all the above mentioned services .free of cost. Non-members
coming from other surrounding villages pay for drugs/dressings and
minor surgery, all preventive and promotive work are given free to
all categories. Table IV below shows the percentage of member and nonneafeor families in each village.
Table IV (percentage of member and non-member families in each village)
Families
Village
Member
Non-member
Total
Mallur
188
202
390
Muthur
63
124
187
Kachahalli
30
21
51
Bhatrenahalli
17
14
31
Ha rlurnaganahalli
6
18
24
304
379
683
45%
55.5%
CONCLUSION
Our experience over the last two and half years have shown
that
i)
A health function can be grafted on to an economic
cooperative
ii) A sound cooperative such as MMC can support
substantially the recurring costs of a health programme
iii) Tagging on of a health function to a cooperative,
benefits not only the members and their families but also the non
members who get indirect benefits of professional services, preventive
and promotive programmes.
The Department of Preventive and Social Medicine and its
staff, was mainly concerned in acting as a catalytic agent, in the
formation of a self sustaining rural community health scheme. An
experiment was embarked upon and the Mallur Project is this experiment.
A Total Health Care Programme can bo effectively delivered through
,6
:6:
a Cooperative in rural areas.
The Mallur Milk Cooperative is even contemplating
construction of a 15 bedded hospital at Mallur, with the help of
Government and its own funds. We are convinced of the responsible
role of Village Leaders in such a programme.
Further, the Health Centre with its working philosophy
has indirectly helped the Department of Prcventiveand Social Medicine
to conceptualise a primary health care system for training of future
physicians, so that they play their rightful role in a contemporary
society.
The Health Team and interns have played an important
role in the development of the village in general and health aspects
in particular. We are fully aware that in the planning of such
self-supporting programmes, the Health Team has to be actively
supported by other members who will attend to the social and economic
development problems of the community. Success or failure;would depend
on tackling the financial side efficiently.
A drive to improve the education of the people including
health education, is to be attempted through use of Village Level
Workers. Their training programme is being organised. Whether
there has been an improvement in the morbidity and mortality statistics
at Mallur, subsequent to the introduction of these cooperatives in
comparison with other areas in the vicirity, needs study and this •
has been taken up as a health project.
The question of introducing such self-sustaining
Cooperative Schemcs to other areas should receive active consideration.
Challenges have to bo met in rural India and we hope that with the
cooperation and participation that is readily forthcoming from the •
simple rural folk, our economic and health projects will meet with
success.
-
/////////////
Table II
M.iLLUR HEALTH COOPERATIVE CENTRE, MALLUR, KOLAR DISTRICT
Receipts and Payments Accounts for the year 1975-76
RECEIPTS
PAYMENTS
38,500.00
Commission on sale
of milk from Dairy
it
Sale of tonics
ti
Doctor1s Home
visit charges
It
720.00
278.00
1,920.00
" Proportionate
charges to Dr.
on housevisits
7,543.68
Rent for intern's
quarters
H
1,200.00
" Dr's Quarters
rent
7,847.60
Treatment of non
members of MPCS 21,082.04
Rs. P.
16,421.73
" Hospital rent
174.81
from MPCS, Muthur
ii
Rs. P.
By Salaries
56.25
" Repairs to
28,903.72 - hospital
331.42,
" Purchase of
drugs
1,869.50
" Hospital necessaries
39,487.
oo
Tc> Contribution
from MPCS
.Rs. P.
1,389.
So
Rs. P*.
Deposits from
staff members
345.00 " Eye camp expenses
76.75
Interest on deposits
30.74 " Advance to'staff
300.00
" Contingencies:
General
Elec, charges
Printing &
Stationery
Entertainment
Charges
Conveyance
Repairs' to
Motor Bike
Repairs to
Typewriter
Demorrhage
charges
Miscellaneous
225.36
672.97
1195.65
224.30
348.80
224.55
40.50
100.98
_J.45.28__
" Furniture
" Advances refunded
to MPCS
" Difference in Accounts
3(578>39
4,421.45
200.00
5,218.55
Total Receipts
Opening Balance
a)-Cash
811.53
b) Bank
1,726.84
77,671.37 Total Expenditure
Closing Balance
a) Cash
2
b) Bank
73,401.30
Grand Total
80,209.74 Grand Total
80,209.74
Sd/Approved Auditor
//copy//
5,401.78
1,406.66
SERVICE RESPONSIBILITY OF A DEPARTMENT OF COMMUNITY MEDICINE
THROUGH A HEALTH CO-OPERATIVE
. .. . . *MAJ GEN B MAHADEVAN PVSM AVSM MBBS DPH., DTM & H.,FRIPHH.,FCCP.,I?PHA
IITROWCTioN
A good and well informed faculty with modern concepts of medical
education, has a Capacity for extensive research in the organisation and
delivery of health services through experiment, models and pilot projects.
Medical educators in general, and faculty staff of departments of Community
Medicine in parti m~l ar, must assume their share of responsibility for meeting
the quantitative as well as qualitative needs of the people and must be
concerned not only with the basic mission of the University or Government
which is learning, but also actively help the people of a locality or region
in organising and running their own Primary Health Care Services.
For establishing an effective and viable Primary Health Care
system, the cooperation of the local community must be ensured. In fact,
the people should be adequately motivated, involved in decision making and
actively participate in health programmes, so that ultimately it becomes
their own "peoples programme". Local resources such as co-operatives,
agriculture, manpower, buildings and most important of all local leadership,
should be used to solve and finance the local health programmes. It is
deX'ir;'bl& that the Primary Health Care system should be a self-sufficient
fiscal entity. Community priorities are more likely to be met if the people
themselves raise and spend the resources required. A "total health" approach
is essential. Promotional, Preventive and Curative care need to be completely
integrated.
THE ’■ CONVENTIONAL APPROACH.
Health facilities in rural areas in the country were provided'
through Primary Health Centres started as part of a national rural
development scheme called ’Community Programmes’ in 1952, with a very
modest staff in each centre to form the nucleus of integrated health
services and cater to the need of about 60,000 population in a Block.
There are now over 5,200 Primary Health Centres, each Centro serving a
population of 80,000 to 120,000. The annual expenditure of morin m
*ne
permitted for each Centro ranges from Rs. 4,000/- to Rs, 6,000/- and this
had to take care of such a Large population. The scheme was extended to
involve Medical Colleges in rural health work and through deliberations of
many committees, the status • of health contres wore improved both qua~l i tat-ivel.y
and quantitatively. An integrated approach of providing health services to
the rural people, with the provision of two doctors to every Primary Health
Centre and a basic health worker with an auxiliary nurse midwife (ANM) to
every 10,000 population, vias attempted.
A Pilot Mobil^-cum-Training-cum-Services Hospital Scheme was
introduced’ in some Medical Colleges with a view to involving medical
and nursing students in rural community medicine. The intention was to
establish ultimately one mobile hospital per medical college. More Medical
Colleges were established with the solo purpose of providing rural
health services. Specialist Carps wore organised for cataract operations,
vasectomy and tuboctomy. Although the Government ,’s
*Profossor and Head of the Dept, of Community Medicine,
St.John’s Medical College, Bangalore 560,034.
.2
idea is to train doctors for rural areas/ those doctors are not
attracted to such areas. The migration of Indian doctors to the more
dewjpped countries -continues.. Even passing of a Parliament Act
which empowers govommont to obligt. doctors ■amL engineers'-bclow age
of 30 to work for a period of 4 years in. .rural areas, remains unsolved
as we arc unable -to provide- reasonable-'living conditions for them
in villages.
Some ,Medici! 'Cpl'l<3ges\ilker Vellore Christian, MediCal. ;Ooli0g<r '
-•'inc6rpprafec(.-'in 'their -teaching- 'progrp^c,1' thb
-rurh!
*
,ditihnsi'ort. in-'a ■
,J■<
significant; way.' The o rgnnisors ' Of ’ the Ccttaunity Health Centre,. have
■
,:
. found!,that 'it costs about Rs. 8. 50 ' per‘p-? ’son yer year,' wltlch' iRpitjies;''' t''
■LabreV5-nfivS,lipr^^^v3?arfi^ui(p.%l^S1li&r?i<!^'0If
gbtc’v§fF8ip>§bWW
... Oe.r:
.gi'"'-.'."- C ': tittsb art io ciox ..ivo'tq -trlJ" ilcri; ,a.[p-q urn o.-a
o-j -v-ih.-J.
°'ldno°
one tine grants',- has es tablished Hc.".TthJ Co-operative's"'fn'-'ifodistrie't!^.";-11-!'".
Doctors * are ^'ri^o0aged^t^Se!$k': s,gll'-ei3¥-ipy^dfi£oift:jita^seO'^oh6.S^at:±-vh’'s' j-T oil*
Doctot^8a®dap^.OT^d±'ik!'?s%pf/fft^t^-!'s'&a^'sf'ifi'3h^r^',^-^S!4t'at-iVo'^l'a<;-i ivj.do.o
c rtain fee i 1 \i c q or’i
’
hein
r
'
'’.
1 J
■One is lo Kin f r ir I inxl l-l - t th^ su-o ss <f tht echcin . The111IJ
" initial reaction 'of'the neople has' been gbod-f 1
-±f -bvij.qno.a-a
r. .1
[ to o ica-rp -qj...;...
i-.ail.liy; hr-. i.-v ooyoffuO
e - i,Jr ' - ’.Voifhtary-'agdnpfes’ have ' established/a UrgeOrninbcr > of f c x- fctapf
-;chdspitais-'iri 'urban areas’^
hospitals'-f&r ranyr: significant orurhlihe’alth ‘work, . althdughoah . f-s.tdnooac at
increasingnumber of dispensable.'. are:,-being -ojenotbljr:wx^^pc'ti®nr-^’fof the country.
• ■1
lo .fpCI lid to 1 doit'han 'ioanolooH
*
....
. . ................. ................. .In'.1 O'.p
q ;p_'. § yf.f. f.-i! ' q.-f u ...i£ :
A-BEVZ STI ilGY
...............
r.JJromLthe'facts andifigures justtgiven; - it ■is...cleaj’--..thctf
Government in< spitefofits hoi: ’loan offorts-ihas1 no.tf been- ahle.e to
seriously' tackle- the- problem anti'-with.' the-'scarbe.allQtmdnts made-. i..
for the -.-health sc-rvic '.s, =h&'• tangible' .improvement') is; po.sfeibie. iri i q :
the near'-future;''"No'-voluntary .‘agency i'Canihopei'.tbr’esib'ai'k;. onya scheme:
where even the- government has failed- but is in a' better'’position to.
try cut now methods-through pilot projects. .When -planning rural: health services., rohp': hasttb‘,consider.. o' . ,
'two- components, namely: the-.: delivery of. package-of rural.- health-. •- -,services in villages and."the forantion. of-personnel who will- deliver-. .
■the same.-At-the same- time,"'there is. an-inescapable'need; fpr? u
.
complementary® services-'-whibhi.&i-ll' deye.lbjh-the?village economy and
. :b
education of. the rural: people.; M-".ny. .rurnl.lroalth.'.scjiertes. talcep,. t-'hor. r r
up enthusiastically at the beginning flounder for lack of popular
.
support that'has. to- be?.expressed>4>y :f-inanciai: ■cont-ribution's-.f This
. ,
is the- crux of the natter.- Any health’ delivery- scheme should be. . .-. ■ ,-.a self-sufficibnt-fiscal' entity. This .hay. be? a-limiting .factor - ...;
■
but'the only sound way of 'attempting, to-s_olY.e;:rurnl.hoal'th-.problons,' :'
is to start-"-iti.infpiaces wore ..conditions.,are .favournblesfpr.-the; -., ■ -,
■ iritrodub-tf&hi-self?-.sup^drt:iin®'^chemps,'. -; , ■ , ;. J.m>
.-.., >;;, j-.-,'.,
ways:
' Funds for rural health sehemes nay bo raised through many
- - - - ■ -• --. . - . ...-
(a) Tagging health,-pb rvi.Qes-it.O -cb-p.peratiye,; -■
- To start.health co-operatives by themselves is
•difficult, as- health holds .a low priority in the felt .needs’ of
the people and -nay not gqt ,-tb.e. ?e piired support ’.in' the .initial •
stages. The. procedure of tagging on'health ser.viC'.‘S,rto existing
co-operatives has. many, advantages - good leadership,.'a ready made-
3
■ ■■
frame work of connunity administration fw
.,r -rr^ctive
health services and community invcriveiaent, as channels of commund
with the people have already been established,- Go-operative Dairying
and Marketing Co-oyox-ativoo of different commodities like grains,
cereals, cottage industrial products otc., lend themselves admirably
to this type of health services.
(b) Running health services with assistance from factory
administration where labourers are fron villages nearby.
A minimal deduction at the source of salary and a contribution
from the factory man-.gement will help to build up the required
funds and formation of a health co-operative. Geographical location
of industries and rural labour in close proximity are limiting factors
but is worthy of trial, in special areas.
(e)
Assistance from Panchayat
Places where Panchayats and the people are interested
in health services and are willing to contribute to the same,nay
venture on this method but unless sufficient funds are forthcoming
regularly and pe 'sistently, the scheme will collapse.
(d) Starting with services and evolving a cooperative at
a later stage.
A devoted team of health workers can establish themselves
in a village and build up the required clientele and popular opinion.
The people can then be induced to form a cooperative and directly
employ the doctor and essential para-medical staff. Until such time,
a central agency or other funding agency may have to meet the
expenses. This can be attemptod ©von without forming a cooperative
in areas of affluence, where people are willing to pay for the health
services and employ the doctor and other staff through collection of
revenue for the purpose.
THE MALLUR MILK CO-OPERATIVE (M.H.C.)
Mallur is a village in Kolar Dist of Karnataka, situated
35 miles from the city of Bangalore. The Mallur Milk'Co-operative
(MMC) was an established concern with a sound and progressive
leadership and had been functioning for many years. In addition to
production and sale of milk, it provided other benefits like
provision of fodder and cattle foods, tractor facilities and
looms at low rates of interest.
Besides the people of Mallur, two other villages, Muthur
and Kachahalli were members of the Co-operative and the total
population covered was about 3,000. These villages had a
farm
coopo.’ative besides cooperative dairying. The economic position
was satisfactory, and, therefore, all conditions were favourable
for the introduction of other self-supporting schemes.
The inspiration for establishment of a Comprehensive Health
Care Programme for the Co-operative Members and their families of
these villages, came from Sr Anne Cummins of Coordinating Agency
for Health planning (CAHP) and Fr Jonas of the Catholic Bishops
Conference of India (CBCl). With these pioneers, the Dean and the
Department of Community Medicine of St John's Medical College,
representatives of the Karnataka Government and Bangalore Government
Dairy with leaders of the Mallur Milk Co-operative,worked out
a scheme for tagging on a health servic ■ to the existing MMC.
The main objectives of the Mallur Health Project were:
a)
to study and devise methods by which the financial
base needed, for. effective ho alt hr-services could
emerge- from the people themsolv-s in a self-sustaining
manner;
b)
to help in the establishment of rural health centres with
the staff and rendering of effective health servic;s to
a wide circle of needy people without distinction of
race, caste or creed;
c)
to study the required strategy and methodology
for the effective rendering of primary health care in
rural areas by trying to determine tho priority areas
in health c.aro and devising the structure found suitable
to village conditions;
d)
to help in those developmental activities which
are very necessary to ensure effective rendering of
health services in rural areas; and
e)
to train intern doctors, nurses and other medical and
para medical staff for the purpose of rendering
assistance in rural areas.
-
The St John's Medical College ana its Department of
Community Medicine, were to be mainly concerned in
acting as a catalytic agency, in the formation of a
self-sustaining rural community h.-alth scheme,
fulfilling the above objectives.
It was estimated that a monthly budget of Rs.2,500-3,000 would
be required for running the Health Cooperative and financial support
was forthcoming by a joint contribution of 3 paise per litre from
the MMC and Bangalore Dairy, in a phased formula as shown in
Table I below. Ultimately the MMC was to completely finance the
scheme.
TABLE I (Contributions to tho Health Co-operative)
Contributions/litre
Year
Milk Co-operative
Bangalore
1st
1 P
2 p
2nd
2 P
3rd
3 P
1 P
nil
Dairy
This budget was adequate to support a health programme,
organised by a Medical Officer, Nurse, Compounder and an Ayah.-The
staff were appointed by the Health Co-operative Committee.
The Health Co-operative Committee included the following members:
Chairman, MMC
Secretary, MMC
Dean, St John’s Medical College, Bangalore
Head of the Dept of Coinmunitjr Medicine, St John's Medical
College, Bangalore
...5
Director/Gc-neral Manager, Bangalore Dairy
Representative of State Health Service
Medical flffi 0.0.35 ..Mall in—Real th. Cooperative (Secretary)
The composition ensured integrated planning between the MMC and Health
Co-operative?.
The Health Co-oporativ’6 got off to a good start by being
inaugurated cn 19 March 1973 by the Minister of Animal Husbandry.
Dr VK Rajkumar a Senior House Officer in St Martha's Hospital,
joined as Resident Medical Officer in charge of the Co-operative.
This Medical Officer by dedicated work and self-sacrifices, made the
MaJ-lur Health Co-operative a successful enterprise.
The Health Co-operative in November 1973 was joined by
another dedicated worker. Maria, an Italian Public Health Nurse, she
with her companion Cathy, a Volunteer from Canada, looked after the
Maternal and Child Health Work.
EB BREAK THROUGH IN THS ECONOMICS OF THE HEALTH CO-OP ER..TIVE
Within five months of starting the project (August 1973)
the cost of foiBsr went up and milk production of the Milk Co-operative
fell as some members began to sell out on higher rates. The MMC took
a decision, much to the discomfiture of the Governmon" Dairy
Authorities, to sell directly to private parties in Bangalore, who
offered better prices. The Govt Dairy therefore stopped its contribution
of 2 paise per litre as health subsidy, and the Health Co-operative
was in a critical situation. It is at this stage a momentous decision
was taken by the responsible village leaders who were more than
convinced of the positive role of the Health Centro and its staff
in improving tho health status of the people in Mallui- and other
villages. The Milk Co-operative was doing well and decided to
contribute 5 paise per litre for health and took over financial
responsibility for running tho Health Centre. This financial strategy
on the part of village lenders resulted in the Project becoming
a viable unit. The Milk Co-operative has borne the entire recurring
costs of the health project ever since, and the table below gives the
Income/Expenditure position for the period July 74 to June 75.
TABLE II (Recurring Costs)
(Year - July 74 to Juno- 75)
Total Milk Production
6,27,898 litres
Income estimated at
5 paise/litre
Rs.31,394.90
Actual'income received
from MMC
Rs.33,100.00
Total expenditure for
the year
Rs.33,790.74
Although the Mallur Health Project is mainly financed by tha-Mallux.
Milk Co-operative, it also receives help and technical direction
from St John's Medical College and the Government Health Service.
These inputs are shown in Table III.
TABLE III (Shows the various inputs)
Source
Capital
z
Recurring
1. Mallur Milk
Co-operative
Buildings,
Furniture,
Refrigerator,
Health Education
Material
Salaries
Rents/electricity
Drugs
General stores
Petrol
2. St John’s
Medical College
■Physician's and
Midwifery Kit
Minor Surgical
Equipment
Lab Equipment
Motor cycle (on
loan through
UNICEF)
Interns services
Specialist services
Rent for interns
quarters
3. Government
Health
Services
Nil
Vaccines,
Vit A, Iron, Folic
Acid supplementary
FP Devices
Surveillance of
communicable
diseases (through
PHC Sidlaghatta)
Health Education
Films (through
Health Education
Department of DHS)
SERVICES RENDERED THROUGH COMMU’ITY PARTICIPATION
■
The St John's Medical College, adopted this Health
Co-operative as a rural training.centre for Interns. Visits by
specialists of o ther departments including specialist camps were
organised. At present, 4 interns are attached at any one time
for whom residential accommodation has been provided by the MMC
on a rental basis. The interns conduct base line demographic surveys,
immunization and school health programmes, special, health projects
and mass health education programmes.
The Health Co-operative Committee moots by turns, at
Mallur and St John's Medical College, to discuss progress and
plan for the future.
The Health Team comprising of Dr Rajkunar, Miss Maria
and Interns under the technical supervision of Dqt of Community
Medicine has made good contact with the villagers and a
comprehensive health care programme has been introduced. The
community of Mallur and other member villages actively participate
in all programme. They have no unreasonable expectations or
demands, as the health project is their own programme brought about
through their own contributions. This is a basic difference between
Health Centres organised through Co-operatives and Governmental
Agencies. The leaders are actively .involved in the panning
.7
.and organisation as the Chain'an, MMC is the Chaiman of the
Health Co-operative 'Committee and the Secretary I'-MC its Belabor.
Parcrwdicul workers are drawn from the village co .unity and
trained for Community Health work. The Young Farrars Association
actively assists in any of the health prcgr'cnes. They help
interns in their'surveys, progrsmesof immunizations and environraontal
sanitation including chlorination Of wells -and construction of
sanitary latrines. They also organise the physical arrangeunts
.or th. Mass Health Education Programmes. The Maliila Mandal
under the dynamic (guidance of Mrs Rajkumar, runs a nursery school
p.nd acts as a forum whore health education, applied nutrition
prograruiesand nothe;craft are taught to ths womenfolk of the villages.
The Health Tom and interns Organise the following
services with community participation.
1.
2.
Curative clinic (daily outpatients)
Maternity and child health services:
i.
antoratal care;
ii. midwifery (domiciliary)
iii.
postnatal care
iv. undcr-5 clinics(doniciliary)
3.
4.
School h-alth s:‘vices for village schools
Immunization programmes for snailpox, triple antigen,
tetanus toxoid, BCG, typhoid and cholera
TB and Leprosy - case detection, treatment and
follow up
Motivation for family planning
Specialist camps at Mallur (periodical visits
by St Martha's Hospital specialists)
Hospital referrals
Family record maintenance
5.
6.
7.
8.
9.
COMMUNITY SERVIC ,S
1. Protection of well water supplies by chlorination
2.
Popularisation and construction of sanitary latrines
and soakago pits and other advise on environmental
sanitation
3.
Collection of health data through periodical surveys
4.
Coordination and cooperation with government
health p rsonnol in National H cilth programme activities
5.
Health Education at personal, gr up and village levels
6.
Nutrition education and nutrition supplementation
programmes.
Me.nb.rs of the Milk Cooperative apd their families are
untitled to all the above m'.ntioned services free of cost. Non-nombors
coning from other surroundin.'. villages pay for drugs/drossings
and minor surgery. All pr vontivo and pronotivo work are given
fr-e to all categories. Table IV below shows the percentage of
member and non-!ie:ibor families in each village.
8
TABLli IV
(percentage of member and hon-meraber families in oajch
village)
——————--- —————-- -------r=—————=r—
Families
‘
Village
Member
Non-nenbcr
Mallur
188
202
390
Muthur
63 •
124
187
Kachahalli
50
21
51
Bhatc renahalli
17
14
31
Harrulunagenahalli
6
18
24
304
379
683
45.%
55.5%
Total
tnrcTEJSW
Our experience- over the last two and half yc-'rs have
shown that;
i)
A health function can be grafted <n to an economic
cooperative
ii)
A sound cooperative such ns KiC can support substantially
the recurring costs of a health programme
iii)
Tagging on of a health function to a co-operative,
benefits not only the members and their families
but also the non-r.c doors who get indirect benefits
of professional services, provsntivo and proiaotivc
pregrn -nos.
The Department of Community Medicine and its staff, was
mainly concerned in acting as a catalytic agent, in the-formation
of a s.^lf-sustaining rural community health scheme. An oxperin.nt
was embarked upon and th; Mallur Project is this exporimant. A
Total Health Care programme can be effectively delivered through
a Cooperative in rural areas. The Mallur Milk Co-operative is
even contemplating construction of a 15 bedded hospital at Mallur,
with the help of Government and its own fun's.
Further, the Health Centro with its work, ng philosophy,
has indirectly helped the D-portnont of Community Medicin-.■ to
conceptualise a primary health car.- system for training of
future physicians, so that they play their rightful role in a
contemporary society.
The- Health Tea:?, and interns have played an important rol.
in the development of the village in general and health aspects
in particular. Attempts ar;, being made to incr rmsc the membership
of tne milk cooperative by purchase of nor cows and incr asing
enrolment. Oth..r economic activities such as development of
village/cottage industries and handicrafts and ensuring sale
of products, are contemplated. Va are xully aware- that in the
planning of such self-supporting programmes, the Health Team
:9:
has to be actively supports'! by other .'lembors who will attend to
the social and economic development probions of the community.
Success or failure would depend on tackling the financial side
efficiently.
The quality of promotive and curative services
would have to be improved. Simpler skills, cheaper drugs and
intermediate technology have to be .introduced to suit rural
conditions. A drive to improve the education of the people
including health education, is to be attempted through use of
Village Level Workers. Their training programme is being
organised. Whether there has boon an improvement in the morbidity
and mortality statistics at Mallur, subsequent to the introduction
of these co-operatives in comparison with other areas in the'
vicinity, needs study and this has been taken up as a health project.
The question of introducing such self-sustaining
Co-operative Schemes to other areas around Bangalore is under
active consideration. These are challenges that have to be met
in rural India and we hope that with the cooperation and
participation that is readily forthcoming from, the simple rural
folk, our economic and health projects will meet with success.
ACKW/LODGEMENT
I wish to thank the "Ad-hoc Committee" of the
z
C.B.C.I. Centre/for in the completion of this paper, I have . ^sw Delhi’
drawn literally on their report "Agency for Community Health’
Assistance in Rural Areas (ACHARA)".
I also would like to thank the staff of my
departnent and Dr Rajkumar of the Mallur Health Centre”,
for their help.
///////////
KG
gOLPKiWEY FHAi/EH AGKhClXEh
CELL
Directory of Coamnity Eeal-th Projects and
Alternative approaches to ’’ealth Care.
( VOLUKT.','::Y AGENGlEy)
1. Indo-Dutch Project f&r
Child Welfare,
6-3-835 --o m.limda
Hyderabad-500004. (Dr.H.«.Butt)
2.
3.
Con.cunity Health Project
Philadelphia Leprosy Hospital,
fcalur Pistrict,
Sxikakulan (Dr.H-.H .Thang^raj)
Areaa-rau Develop sent Society
■^danapulle Taluk, •
Chittoor District *
4. R Arogyakferaa Development
Society,
iudanpalle Taluk,Chit toor
5. Health Progress?® a
Andhra ;-ahila Sabha,
University Road,
Hyderabad.
ixxa aim
1. Cori'.iunity Health Project
Kurji Holy la-.ily Hospital
P.O.iadaouat A ah ran,
Patna.
A gricultural euj-
Dove1c
Project
Krishi -a-suduyik Vikas
X o jana, - aLi.jau,
Bh and oris .slock, Bihar
3« Brothers to All Hen
International,
P.O. Buniadg&nj,Gaya
*
823003
4.
Xavier Institute of
Social Service,PB lio.9
Hanchi-834001•
5.
6.Village reconstruction Organisation,
6/9 Brodipet,Guntur
(Prof. J ..•> .vlindey S.J.)
rsaaanyaya Ash ran,
Bodh Gnya.
6.
7. Coasunity Health Project
Hayalaseeaa Development Trust
Anantpur (Dr.fitn-.v-)
Gri.a BHarati Garvodaya
raa,1'. G.Siaultala
d11316,»iet.Uon^hyr.
7.
8. Goa unity Health Project
• CGI Hcapital,Janal^adugu
Dist.Cuddapat (Dy.G..rthur Gaauel)
Co-.-icunity health Project
Holy ~ .•i'_lly Hospital,
Kurji- Patna
SxxsjkkiK
9. Swallows Hospital,
Hajupete,Choidiganipalli P.O.
vic V.Kotu 517424
Chittoor District
(Hiss .>.ria G.Zilloli-JfTK)
1. Okhla Kcii-hbouxhood
Coaprehensive Health &
WeIfare Pro ject,Holy
Pa-ally Hospital,
Jaraia-Okhla,i’ey De Pii
10. Cc-ranity Health Projects
C. I Victoria Hospital
jLj- ...alii ,Dist.fii3OEiabad
503175 A.P,(Dr.L. .UHogsrseil)
lit.
Gr,
2.
nobile Crc(j ea for
Working Bothers,
5B Tele t:. i Lane
Hew Delhi-110001.
3.
Voluntary He?.It: AssoclA
C-14,0oi.'.:iunity lev.
Centre«D.A. Hew Delhi
-16.
(Dr.Murray Laugeaon)
(Dr.Ruth Hamer)
4.
Aural health irg.Centre,
Na jaffS&ih ,De Ihi.
^>1..
1. Total -calth Care Project
Taaulpur Block,
Kaurup District.
2.
faaulpur Anchalik Graadan
San^i, Huaarlkata 781360
Bist. Kunrau.
1. Bochesasn Gujarat Blind -'-elief
and. : ’ e. .1th . as ociuti cn( C&>JIA )
Chikod
nnnd Taluka,
Kaixu Bist.(Dr.ii.R.Poaihi)
2.
Jodico Friend Circle
21,N irntun G oeie ty,
Vudcdar; -390005
(shok Bh argava)
2. Village Health worker Trg.
Scheese pro; ect
(John Bishop -“esiorial hospital)
Uh ioh urpura /i rea,
Amntnag Bist.
(T»r.I; .Xavier -IS )
Zanily Survival .jCurance Plan
(C -Al) Ph.ildelphia ’’oenital
Aabala(Hnryunu)
3.
V,H•*.■'. SchootS,
Lady Willin
' os it
'JnrinH^ulu Bist.
(Dr.u. ..haul proj.Bir.)
KAKls .".".k'a
1. I
?..■'? R Tin® GSHTHE
? lallur-Sid^d^1 a't-a •
Kolar I>ist.(Jr.~-avi Burayan)
( iu j . Gen . 3. ’.tah ad evan)
(Dr .V.Hana .Kao)
2. Hirnala Health Centre,
Syluroyuro
I.e-z :• cssura^atta.
(Dr.^ercy r'tujticken)
?. Con:iunity TTes.lt- Project
St.Barthas Hospital,
Bruptunga - .OLd,
Bangalore-560009
(Hr.i’ara ■■nor)
Cot -.unity Health Projeot
C.O.I. Ho epi tal,Ban galore
(By.Ben j aain)
5. Comunity Health Project
Baptist .iseion hospital,
Hebiau 1 ,Banga lor e.
4.
6.
1. Hehhar-I-Sehat
Pilot Project,
J&K Govt.
MEDICARE
.redic :l -elief -ocioty
K&sturba Icd.Coll&ye
PB 8,-!anip&l 57511J
(Br.ji. ."ris'rm auo)
Senate:n ’illage Project
John Bishop ’lenOTial Hospital
Anantm g.
1. Family Survival -Assurance Plan
ondi’lcapadanInndirata Hospital
2. Dr.T.n.Jayac?andran.
Registrar of CoqaHocieties,
Kerala,Privandrun.
3. -i.V.George,Chief Hv-^luation
*Jfj.xcor,--t-.-te x'lxnning .Board
'Irivandrua.
4.siitraniketan, . v.Vellarud
695543, Bist .IrivandruBi
Kers 1
;;.y •. ■
i
Gandhi Bhav>'xn,PG Thyoaud
Trivandrun 695014
fi.MADIIYA 1? BADES?
1. Cosnamity I'ealt’ -reject,
Christian Hospital
Cliat tarpur,Via Harp&lpur.
2. Eldora Bhsrati
Vill.iulia Piparia
P0- dalharwada vi<x— <-nk’•• edi
Bist .’’os’-, angabad-461990
(Anil Sadgopal)
tod "etilth Services
<ro.lect- ■ --Tless i'osp. iiraj
-led.Centre ,hiro.j ,Dist.Sangli
(Pr.Eric . 'an,Project Dir.)
5.
42, liur&l Her.lt' Research Project
The foundation for <-csearch in
C ou .'.unity ? ’ealt
'
*
,
48 A,Abdul Gafft.r Khan rid.
World! Bombay
(Pr.N.F .Knit Antia-Trustee)
3
1. - . •
I-J.. ..E
G,.. it: -India
Greater Kailas ,
hew Delhi.
(Dr.iara Gopnltias)
2. Pftdhar Hospital Community .
■'em 1th Pro.ict,
PC Padhar, petal Slat.
(Dr.C.'icss ^ir.)
•
■-. - -u.
Poundfor--Aesearch In
eo-.-u.;!;
calth,
V.i>hoi<iwde PO
iiwa.8 -ist, KoL'iba
(lir.j ’.rs.Aloke i'ukherjee)
Comprehensive Hural 5 'ealth
Pro je c t, J i lakh e d
Di st.AhmednagaHDr. •' ■ -A role)
Dir.
Z ;-.:iily Jurvival asonr;ince Plan
Dvcngelvie Booth Hospital
;.h sdnagar.
Kapa yodel Integrated
;! other-chi Id HenltJ Nutrition
irOjCOt-: ' v
Daluka i bnnu ,Dist. ’•-■’■ ? r.n
(Prof
I .Shah)
Pal£ ur I reject
Diet. Th am
?.
*
(Prof
i.Shah)
Kasturba ’’ealt
*
Society,
Lewcgraa,s-;irc3’.a 442102
(Dr.Sushila Layar)
Appasaheb satuardhtin '-emorial Trust
llahatse. 'Sandhi Seva -andir,
252, -.¥. .cad.Ikmdra Seat
BQibay-430050
■-’.:.li’........ U;eagiri;
Auri:\,
Dis’i.
( ir.Vinod Parekh)
Compre’ 'nnivs Peal th Car® &
^)ev. - - ■
fission ’oo. i’,.-1,
. xaehoot
Di st. .urangiJxul.
Cosinunity Health Project
Chichipada Chrieti&n Hospital,
Dhulia Diet.
Janta Shikshan --andal
Sone Guruji Vidya *
r bedhini
XJ\ i roda, Ta 1 ga on D1 st.
(Jchn.Sorrier,Pord foundation)
Hural i'ealtv Project,Sirur
Poona Diet.(Ur.h .DeodMr)
Uruli Deraohi-S1- a jeevan
-r.udhyogik '..•■u-rkari Society jtd.
Bade Sutra i■ all,‘’adpsar-Poona-28
(Mr.Virendra Kabra)
Mah&rogi S©Wa Sailti
Dattnpur 442C'J1
Diet.f-.-ardh a
NAGALaIu)
Peach err Trainiaj
Paramedical Trg.institute,Kohima
ORISSA
Community ealt’- Project,
Christiar. n03<>ital,
P.O.Mowranjyur,
Koareput Aiitvlet 764G59
Comunity ’’ealtb 1 reject
Christian Hospitc.1,
V .Dipt i; ux
* , Dis t. Ga-ibalpur.
(«i83 'iarilyn Jills)
-Agriculture A’raininj -"-entre
Gopulwaii po. AntTinada
via Hajayou-.',765001
onput
PUNJAB
Community i'eaa.tv’ i-r :.yrt‘x.i.je
i-ac Robert '
-1
D’’ ariwal.Die t ♦• ?•:; ■ s^xtr
(Dy.i.b .Uberol)
4
Yolunta.ry ’’©alt?.' Services Se^eae,
V.'edical Centre,
Adayar, 'adras.
(Ur.K.L’.SBnjivi)
Sewa ftandir
Hdaipui-513001
(Dr.:iev ta)
UTTAjl -t'RADESFf
J'-anily . ■. rvival .-Bsurance Plan,
,jc jicu ■ " capital,
Aaibur.
CoaTiunity ?:ealt- rrogranre,
.'lothodist "icoion hospital,
-Jai sin ;:u r., lathura
(Br.E.B.Ssjsdnran i'L)
Deenbandhu edicol Usaicn
ret-651505
Dist.'-hii^lepn.t
(-’r.Ircn Chander John)
Go iiunity Fecit1’ Project
Pan-let Besson e norinl ,rosp.
ir.litpur,-P-tinsi Diet.
(Dr.^.^.Bac'-an)
Comprehensive labour Welfare Scheme,
United Planterrs association of
£. xndi8,( UpA§I)
u I.? uylew, 0 oonobr-1Ii Igiri
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*ullsh)
The ■ ^rlndus Institute
Banwasi Ocva As’' ran, Hovind pur
via Turr- :■. ,Dist .’.'irzapur.
Con••lunity health A’ro,1ect
kottar Social Service Society
ir;rax.ri Di st.
c/o Biahopa -’ou^,?B 17
Nageruoil 52J001
Co r-iunit’’ei It- * ro - -?ot
c-.risit-an idle dip ’’osp.Centre,
V. Oddanc1 atra-?., 52461 j
aist. ^dr.iroi(Sr..’-.;cob Cherias)
Child Care Centre --md Nutrition
Hehabilitation Centre
. ladunai, Govt, “rskinc TTosp,
(i’r. C.VeiikataBweay)
F'ea 1th ,Nutrition ft Pl Centre
SwallowB in India,
i'esic -,ag:.r,i‘e'.-' asheriBanoet
Uadrae-QI.
ibiJ
Community ;-®alth ^rograiune,
x'’e soeiui work ■'• Research Centre,
lilonia i*
.o.
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