POOJA SHETTY.pdf
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2022-23
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Community Health Learning
Programme
POOJA J SHETTY
A Report on the Community Health Learning Experience
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ACKNOWLEDGEMENT
I would like to acknowledge the Program Directors, Senior Advisors, Facilitators and Office
staff at SOCHARA for putting together and facilitating such a comprehensive program on
Community Health Learning. A special thanks to Karthikeyan K and Janelle Fernandes,
Associate Directors for their constant encouragement and support in enabling me to complete
the Community Health Learning Program. My sincere gratitude to Uma Chaitanya for her
mentoring, guidance and support.
I would like to express my special gratitude to my Mentor Dr Rajeev B R, for his able guidance
through the Community Health Learning Process and in execution of the Community Health
Action Project.
I would like to credit the Anganwadi Supervisors, Anganwadi workers, family members and
children for their active participation and involvement in the Oral health promotion of children,
without whom this project wouldn’t have been possible.
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CONTENT
PART- A
CHLP LEARNING
1. WHY DID I JOIN THE FELLOWSHIP?
2. WHAT WERE MY LEARNING OBJECTIVES AND WERE THEY MET?
3. LEARNING FROM MODULES AND HOW I APPLIED THE LEARNING.
4. REFLECTIONS ON USE OF THE LMS, VIDEOS AND PARTICIPATION IN
LIVE ONLINE SESSIONS.
5. HOW WAS A BALANCE BETWEEN WORK, LIFE AND THE CHLP
MAINTAINED?
6. MENTORSHIP PROCESS AND REFLECTIONS
7. PROJECT LEARNING EXPERIENCE
8. TAKE AWAY FROM CHLP AND LOOKING AHEAD
9. IMPACT OF COVID-19
PART- B
COMMUNITY-BASED HEALTH ACTION-REFLECTION PROJECT
1. BACKGROUND
2. OBJECTIVE OF THE COMMUNITY HEALTH ACTION INITIATIVE
3. DESCRIPTION OF THE INTERVENTION AND IMPLEMENTATION,
COMMUNITY ENGAGEMENT PROCESS
4. IMPACT OF THE COMMUNITY HEALTH ACTION
5. LEARNING AND REFLECTION
6. PHOTOGRAPHS
7. REFERENCES
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PART- A
CHLP LEARNING
1. WHY DID I JOIN THE FELLOWSHIP?
I am a Public Health Dentist who has been working towards Public Health problems
using the Public Health Approach. One of our Post Graduate Alumni forwarded to me
the details of the Community Health Learning Program(CHLP) of the Society for
Community Health Awareness, Research and Action(SOCHARA). She had also
recommended it as a good program.
I was initially sceptical about enrolling for the course. But when I went through the
work of SOCHARA and details of what this fellowship had to offer, I realized that
getting an opportunity to be a part of this fellowship would be a real eye-opener for
me, my Learning process and my work.
I felt that this fellowship would enable me to transition from the public health
approach to the community health approach for public health problems with the
involvement of the community and other stakeholders.
I felt that being a student of SOCHARA will help me to learn from their community
health practices. This program will empower me to explore the social determinants of
health based on community needs and experiences. It has also allowed me to interact
and learn from others' rich experiences and practices as the other participants come
from diverse backgrounds working towards the common goal of health for all.
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2. WHAT WERE MY LEARNING OBJECTIVES AND WERE THEY MET?
My Learning Objectives:
By the end of this programme, I wanted to acquire knowledge and develop the skills
to Capacitate the communities to plan and implement oral health promotional
activities
My Strategies to achieve the learning objectives included:
Identifying the oral health needs of the community and barriers to oral health care in
the community
Identify and train some of the community members to carry out oral health
promotional activities in their community
My Area of Interest was:
Oral Health promotion
Were the Learning Objectives Met?
Yes, the modules and the community health action project empowered me in
achieving my learning objective.
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3. LEARNING FROM MODULES AND HOW I APPLIED THE LEARNING
The modules comprised of various aspects of community based action approach. This
was a new learning process for me and initially it was difficult for me to understand the
distinction between public health approach and community based action approach. The
modules comprising of educative videos, live interactive sessions, reading materials on
various topics helped me understand the theory and practice of community based action
approach.
REFLECTIONS ON SOME OF THE MODULES:
REFLECTIONS: MODULE 2: UNDERSTANDING COMMUNITY HEALTH
This module introduced us to the Community Health Approach to solving public health
problems.
The key principles of the Community Health Approach and the Axioms of Community
Health were explained in this module with practical illustrations, to facilitate better
understanding.
The Axioms of Community Health were explained with the example of the Adivasi
Tribal population of Gudaluru.
Axiom 1: Rights and Responsibilities
The community exercises their responsibility to attain good health and demands health
as its right. People need to understand that health is their right and they need to demand
collectively for it. Without the active participation of the community, any healthcare
system is bound to fail. It is the momentum which keeps the health care system in
motion. As explained, in the example of the Adivasi Tribal population, the Health
Animators meet and the Anti liquor demonstrations are examples of people coming
together to ask for their rights. As evidenced in the video about the Tribal population,
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it has been told that initially the tribal people were scared to look at other people or
venture out, but gradually they started to fight for their rights.
Axiom 2: Autonomy over Health
The community health approach believes in capacitating people and the communities
in making their own informed decisions about their health and healthcare. It involves
community participation and improved accessibility, affordability, adaptability and
availability of health care services.
Axiom 3: Integration of health and development activities
For better community health, it is better to have intersectoral coordination with different
sectors like education etc. Improving education, providing job opportunities, marketing
products manufactured by the Tribal population and making them self-reliant is also
necessary.
Axiom 4: Decentralized Democracy at the community level
There should be integration between the community and the health sectors. There
should be no hierarchy in accessing healthcare. The Community Health approach
should be a people-building, people empowering and people participating activity.
Axiom 5: Building equity and empowering community beyond the social conflicts
There is usually a social hierarchy which exists in a community, which will prevent full
participation in health care by a community. It is essential that such a social hierarchy
must be removed and people of different social groups must participate together to
achieve health.
Axiom 6: Promoting and enhancing the sense of community
Various social, religious, cultural and political differences divide the society at large.
Various cultural events, gatherings or confrontation with other entities brings unity
among people of a given area and brings a sense of WE feel.
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Axiom 7: Confronting the Biomedical model with new attitudes, skills and
approaches
Using locally relevant resources should be used and the social dimensions of health
should also be explored
Axiom 8: Confronting the existing superstructure of Medical/healthcare to be
more people and community-oriented
The people from the community should be trained to provide or promote Healthcare in
the community. For example, Tribal Animators or traditional healthcare workers could
be the messengers of health-promoting activities.
Axiom 9: New vision of health and healthcare and not a professional package of
actions
Community Health Approach is not just a speciality or just a new discipline. It is a new
perspective of healthcare, less technical and considers the social determinants of health
and believes in reaching out to the community. It is made by the People, For the People.
Axiom 10: Effort to build a system where Health For All becomes a reality
Community Health Approach tends to build a new system where Health For All
becomes a reality. It believes in removing the barriers to access health for all. They are
the means to achieve health and not the end, hence they are flexible enough to be
modified or reorient.
The community health approach believes that as the determinant of disease is mainly
economic and social, its remedies should also be economic and social. (Prof. Geoffrey
Rose, 1992)
The key principles of the Community Health Approach involve:
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1. Community Participation
Community participation is an important component of a healthcare system without
which healthcare services will fail. Community-led action and empowering the
community to take leadership in health matters are essential. Bare Foot Doctors in
China and Village Health Guides in India are classic examples of improving community
participation.
2.
Community Health Workers
Village health committed and voluntary health workers from the community itself are
needed who neer suitable training. Accredited Social Health Activist (ASHA) workers
help to promote access to improved healthcare at the household level.
3.
Deepening Democracy
A fully democratic process is required for achieving Health For All. A Decentralized
Democracy at the community level should be built, with equal representation from all
the sections of the community without any social hierarchy.
4.
Equal stakeholders- power shifting
Communities Should be involved in the designing, staffing and functioning of the local
Primary Health Centre.
5.
Health as a right
People have the right to participate individually and collectively in the planning and
implementation of healthcare services.
Reflections on the Community Health Programmes of SOCHARA with the
Community Health Approaches (Group exercise)
TRAINING COMMUNITY HEALTH WORKERS
"No permanent improvement of public health can be achieved without
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the active participation of the people in the local health
programme... (Bhore Committee, 1946)
• 1997 to 2001 -Jan Swasthya Rakshak Scheme and Its Evaluation
• 2001 – 2005 - The Mitanins of Chhattisgarh
• 2007 - CHW - Pedagogy and Practice
Community participation was improved by training unemployed rural youth, the
healthcare workers
• Community Healthcare workers were trained to improve access to healthcare
• A people-centred paradigm for health and development was promoted, envisioned
through a community health movement and a community health approach to
public health problems
COMMUNITY MONITORING – COMMUNITY ACTION FOR HEALTH IN
TAMILNADU
• This project addresses Community Participation, Training of Community
Health Workers and also the formation of village-level committees.
• It also addresses the principle of Deepening Democracy, Equal
stakeholders and Health as a Right.
• Here people are actively participating individually and collectively in the
planning and implementation of healthcare.
DISASTER RESPONSE
• Over the years SOCHARA has responded to a range of disasters in South
Asia and it can be seen that Health is a political struggle.
• Here we can see that Efforts toward policy changes were taken
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• Community participation was improved by preparing volunteers before
heading for a disaster response
• Community Healthcare workers' training was also carried out for
Disaster response
ENVIRONMENTAL AND OCCUPATIONAL HEALTH
• In SOCHARA’s response to Environmental and occupational health we can
see that the challenges were met by an interplay of various principles of
Community Health Approach
• Action undertaken by the team led to experiences in participatory research,
lay epidemiology, policy advocacy, health promotion, communication,
networking, capacity building, multi-stakeholder dialogue, governance, legal
and ethical issues and the challenges of representing the voice of the people
CONTROL OF VECTOR-BORNE DISEASES
• In their action for Control of Vector-Borne Diseases we can see that
Community Participation was improved, Deepening of Democracy was
seen, and Health was seen as a right.
• The community was encouraged to participate, they were trained and
empowered and capacity building was carried out
IMPROVEMENT IN SANITATION
• SOCHARA has tried to improve community participation in rural areas of
Karnataka by conducting training through “Community-Led Total
The sanitation” method is a process of facilitating participatory
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exercises using different tools
PREVENTION AND CONTROL OF SUBSTANCE ABUSE
• SOCHARA has worked towards policy issues, which highlights that
health is a political struggle.
• Students of schools and colleges and street children have been involved
in controlling and preventing substance abuse as they are a vulnerable
population. This approach helps in improving community participation
and making them realise that Health is a right and they can contribute to
achieving the given health objective.
URBAN HEALTH
• SOCHARA has been involved with urban health work since its inception
• They have worked towards improving community participation, training
of community health workers and working towards implementation of
health policies.
CONCLUSION
• In conclusion, it is evident that SOCHARA has adopted the Community
Health Approach in tackling various issues affecting the public.
• Community is an active participant in their approaches to health.
• Various educational, training and policy actions have been undertaken
by the organisation
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REFLECTIONS: MODULE 2: UNDERSTANDING COMMUNITY HEALTH –
PART II
In module 2 of understanding Community Health, the Social- Economic- Political Cultural- Ecological Determinants of health were discussed in detail. The
interconnectivity of various Determinants in causing a given health Problem was
reflected. The Determinants for Covid-19 and the food crisis were also discussed.
Controlling the determinant which caused most of the health issues would lead to the
maximum resolution of the problem. Priority was given to the liberalization of health
services by removing all barriers rather than equity. Special mention was made of the
nutcracker effect where a top-down and a bottom-up approach with the involvement of
different stakeholders and sectors was essential for achieving Health For All.
The videos on Community Health Approach to COVID-19 and the Sanghamitra Project
highlighted the importance of the involvement of the community for the successful
implementation of any health program. The work of the grassroots level primary
healthcare workers was highlighted. How community participation plays a vital role in
providing momentum to the health programs was explicitly shown.
In my field of work, we regularly see that certain target populations like rural
populations, elderly people, migrant workers, and slum dwellers face a lot of barriers
in accessing oral health care. It could be accessibility issues, affordability issues, or
awareness issues. Learning about the SEPCE Determinants of health will enable me to
apply them to public health problems, analyse the problem and formulate sustainable
solutions to the same.
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I have been a part of activities where we have trained ASHA workers, Anganwadi
workers and school teachers to be channels/leaders of change to promote oral health
and to work towards Tobacco Control, in the communities where they live and work
with. It is essential to Assess the barriers they would have faced in the implementation
of the same which has not been analyzed. This module will guide me towards the
planning and implementation of future programs so that suitable modifications can be
made based on the needs of the community and for better involvement of the
community.
We had an assignment of reflecting on THE COVID-19 CRISIS AND PEOPLE’S
RIGHT TO FOOD using SEPCE determinants. The Reflections of the assignment
are as follows:
The COVID-19 crisis in India and the impending Lockdown brought to the limelight,
above all other issues people’s struggle to satisfy their basic necessity of life –“FOOD”.
Every individual has the right to food.
It is a component of the physiological needs forming the base of the pyramid, in the
hierarchy of needs.
A statement commonly heard was “Forget COVID – We will die of hunger.”
A vast number of migrants in the country feared death from Hunger than Death from
Disease (COVID-19).
In the COVID-19 crisis and people's right to food, the SEPCE Determinants were as
follows:
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SOCIAL DETERMINANTS include:
Lack of education, lack of employment, lack of assets, Migration, Seasonal work and
income, Poor work and living conditions, Delay/loss/non-payment of wages, lack of
access to relief, Poor health and lack of access to health, Identity issues, Many families
members to feed and support.
ECONOMIC DETERMINANTS include:
Lack of education, lack of employment, lack of assets, Seasonal work and income,
Delay/loss/non-payment of wages, poor health and lack of access to health, Poor living
conditions, and No Bank account.
POLITICAL DETERMINANTS include:
Ration card issues/Non-portability, Non-linking of Aadhaar and Bank, Lack of
Transport,
Lack of good PDS, Lack of access to health care, Lack of workplace regulation and
monitoring.
CULTURAL DETERMINANTS include:
Lack of education, Migration, Exploitation, Poor living conditions, and Male
dominance.
ECOLOGICAL DETERMINANTS include:
Seasonal Income, Seasonal Employment, Poor Living Conditions, No assets, Poor
health and healthcare access
COVID-19 and the food crisis were just an eye-opener to the already prevalent
conditions of the migrants in the country. Liberalisation and the nutcracker effect are
required for sustainable changes to take place.
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REFLECTIONS: MODULE 4- RIGHT TO HEALTH AND ACCESS TO
HEALTH CARE
The right to health is a fundamental human right. The World Health Organization has
always upheld this right to health. Health has been defined as a state of complete
physical, mental and social well-being and not merely the absence of disease. Several
countries have ratified the same. Many countries have adopted the right to health within
the constitutional framework of the country. Until and unless the right to health is
adapted to each country's constitution, it may not be enforced in the country.
Systematic planning has been carried out for healthcare services delivery in India since
the formation of the Bhore Committee, but the right to health is not a part of our
constitutional framework. There is no explicit mention within the constitution, though
it has been considered an integral part of Article 21 of the Constitution, which upholds
the "Right to Life". Time and again the Judiciary system of the country has upheld that
the Right to Health is a part of the Right to Life and the States should take responsibility
for the same.
Repeatedly the loopholes in the healthcare system of the country have been obvious to
us, but the COVID-19 pandemic bared the inadequacies of the healthcare services in
providing Health For All. We have seen people struggle for the treatment of
emergencies, and people not able to get treatment for other infectious or chronic
diseases. We have seen the horrors of the struggle for a bed for treatment, lack of
oxygen and ventilators, and the never-ending inflating health care costs pushing the
already poor people into the abyss of no return.
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India lacks the healthcare workforce and healthcare facilities and infrastructure. There
is a lack of community-oriented training for physicians. It is people going in search of
accessible and affordable healthcare rather than healthcare coming to people's
doorsteps. For people already living in poverty, accessing healthcare is a loss of work
hours and wages for their bare minimum necessities. Though there are a lot of
Government schemes available, many eligible people are not aware of such services
and many more are ineligible for want of documentation like Aadhaar, Ration card etc.
The Government health services/schemes are not functioning effectively for varied
reasons. The private health sectors which work in coordination with Government health
sectors are not always cooperative towards the implementation of Government schemes
for the needy due to reasons such as the non-release of funds by the government, as
these sectors work for a profit.
When it comes to the middle-income group, they are the worst affected when it comes
to accessing healthcare in case they have not enrolled on any health insurance schemes,
as is the case with the majority of the population of the country. The health care costs
are expensive and they aren't eligible for many of the government health schemes.
Solving a health problem is usually catastrophic to such families.
As health is a basic right of every individual, health care should be accessible and
affordable for all without discrimination based on gender, caste, region, religion or
socioeconomic status.
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REFLECTIONS: MODULE 9- HEALTH SYSTEMS IN INDIA
India is the second most populous country in the world and the healthcare system is
overburdened as the healthcare system is insufficient to meet the needs of the growing
population.
This imposes a set of health challenges unique to the country.
India's Healthcare comprises of Primary, Secondary and Tertiary Healthcare.
The Healthcare system should focus on the local health conditions, provide sustainable
solutions which are accessible, affordable, acceptable and suitable to the local needs.
Continuous evaluation and suitable modifications are necessary.
Here is a reflection on the country's Healthcare Delivery:
LEADERSHIP AND GOVERNANCE
STRENGTH
Good number of health policies, programs and services
Commitment to enhance budget for health.
WEAKNESS
Poor enforcement of health policies, programs, services
Lack of awareness about the facilities available
GAP in situation analysis and policy implementation
More out of pocket expenditure
Inequity
Schemes not working effectively – claims not paid
OPPORTUNITIES
Commitment of the government to improve the present situation
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Policy of the government towards decentralization presents the potential for bringing
about the desired changes
CHALLENGES
Lack of Faith in people in the existing healthcare system
Political interference
HEALTH WORKFORCE
STRENGTH
Continuous increase in number of doctors and other medical professionals
Very large workforce of volunteers
Good number of oncologists in the country
WEAKNESS
Lack of skilled workforce
Shortage of manpower
Skewed distribution
Lack of long term retention of workforce
Rural shortage of staff
There is shortage of surgeons, gynaecologist, physicians and pediatrician in rural India
where 60% of population reside.
There is a shortfall of specialists at CHCS
Shortage of trained Paramedics
Majority of oncologists are in rural areas, hence there is a shortage in rural areas.
The WHO recommended Doctor to Patient ratio is 1:1,000 but in India it is 1:1,511.
The WHO recommended Nurse to Patient ratio is 1:300 but in India it is 1:670
Healthcare workers suffer from stress and burnout.
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The staff are Overburdened
OPPORTUNITIES
Large employable population
Large number of Medical colleges
Posting Undergraduates and Postgraduates in Government sectors
Reorientation of Medical Education
Support local Healthcare Workers and provide suitable incentives
CHALLENGES
Private sector, which is lucrative is very inviting for the medical and allied health
workers
Private practice
Overburdened staff
INFORMATION
STRENGTH
Rising health awareness among some population groups
WEAKNESS
Lack of updated guidelines and training to the health care workers
Lack of information about Healthcare services available
OPPORTUNITIES
Create Awareness about prevention of diseases, hygiene, Government schemes,
services and policies
Reorientation of medical education
Updated and Regular Training for Healthcare Workers
Utilize technological advances for awareness
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CHALLENGES
Reaching out to the hard to reach population
FINANCING
STRENGTH
Presence of a large network of all kinds of banks, financial institutions, life and general
(including medical) insurance companies
Commitment to enhance budget for health by Government
There are several Government backed schemes
WEAKNESS
High out-of-pocket expenditure
Low budget allocation/inadequate public spending on health
Failure of states to utilize funds
Low insurance coverage
Problems of tracking in schemes for utilisation
Ineffective auditing
Inequities
Lack of Resources
The Government schemes are not functioning effectively, only 65% claims are paid.
OPPORTUNITIES
Availability of funds
Opportunity for states to spend
Government should spend more on healthcare
Integrate with NGOs, Private Sectors and other agencies working towards public health
Rising importance of health insurance
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CHALLENGES
Corruption
Neglect
Expenditure for private Hospitals are more among people
MEDICAL PRODUCTS, VACCINE AND TECHNOLOGY
STRENGTH
World class medical technology, equipment's and facilities
Domestic Production of generics at low cost
Domestic capability to manufacture most medicines
WEAKNESS
Inequitable distribution
Poor Supply
Difficult to co-ordinate and regulate the pharmaceutical sector
OPPORTUNITIES
Increasing domestic market for production of devices, diagnostics, technology and
equipment
Increasing domestic focus on generics
High demand for drugs
Rising purchasing power
Untapped potential of the rural markets
Reset research agenda and involve medical colleges, private practitioners and
Government Doctors
CHALLENGES
Lack of faith in local products/technology
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Ethical issues
INFRASTRUCTURE
STRENGTH
Emergence of number of hospitals and facilities
There is continuous increase in number of hospitals, diagnostic centres, doctors and
other medical professionals
Numerous medical colleges
WEAKNESS
Inequitable distribution
Problem of supporting infrastructure like road, transport, power, water etc
Inadequate number of hospitals
Poor maintenance
In India, 60% of hospital beds are in Private sector
WHO recommends 5 beds for 1000 people, India has 1.4 beds for 1000 people while
the Government sector has 0.5 beds for 1000 people.
There is a shortfall of Sub centres by 23%, Primary Health Centres by 28% and
Community Health Centres by 37%
OPPORTUNITIES
Large number of Medical colleges
Healthcare services should be accessible in Medical colleges
Medical Colleges should be based on requirement of the District
District Hospitals should be strengthened
CHALLENGES
Lack of resources
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Medical colleges focus mostly on needs of education rather than needs of healthcare
services
HEALTH SERVICE DELIVERY
STRENGTH
Elaborate and functional structure and system
WEAKNESS
Not meeting the Growing Demand for quality in healthcare
Lack of inter-sectoral coordination and convergence
Unregulated commercialisation
Lack of monitoring and evaluation
Lack of Data
Inequity
Not accessible
Mental health is neglected
Focus is more on curative less on Preventive care
OPPORTUNITIES
Massive domestic demand for healthcare services
Many involved departments, if coordinated, can help achieve better health
Must be made appropriate, accessible and affordable
Equitable distribution
Planning to attend to the Gaps observed in healthcare delivery
Should focus on prevalent public health conditions on tests and treatment which are
more cost effective and locally available.
CHALLENGES
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Political interference
Redefinition may face pressure from Professional bodies, regulatory agencies,
corporate hospitals and pharmaceuticals
BIBLIOGRAPHY
1. Thakur H. A strengths, weaknesses, opportunities, and threats analysis of public health
in India in the context of COVID-19 pandemic. Indian J Community Med 2021;46:13.
2. Zachariah A. Tertiary Healthcare within a Universal System. Economic and Political
Weekly 2012; 47(12).
3. Anuradha S, Sheriff DS. Health Care Delivery in India - SWOT Analysis. ParipexIndian Journal of Research 2019; 8(8): 1-4.
4. Mathur B. After Seven Decades of Independence, Why Is Health Still Not A
Fundamental Right In India? Published on October 2nd, 2021. Accessed from
https://swachhindia.ndtv.com/after-seven-decades-of-independence-why-is-healthstill-not-a-fundamental-right-in-india-63139/amp/
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REFLECTIONS: MODULE 10- PLURALISM IN HEALTH CARE IN INDIA ROLE OF LOCAL HEALTH TRADITIONS AND AYUSH
Pluralism is the use of more than one healthcare system for the treatment of illnesses.
Pluralism has been very common in Healthcare in India since ancient times. It might be
prevalent due to the limitations of the allopathy-based health system like inadequate
mainstream health infrastructure, lack of manpower, lack of resources, lack of access
and quality of care. Pluralism comprises multiple views of efficacy, cure and care. The
presence of Indian systems of medicine are generated and sustained due to the lived
experience of the people, the local needs and availability of resources. In India there
are codified and non-codified systems of Traditional medicine. The existence of
pluralism suggests the need to develop an integrated approach for healthcare services.
Integrated Systems of Medicines were included in the National Rural Health Mission
launched in 2005. Later, in 2014, a separate Ministry of AYUSH was instituted. The
National Health Policy 2017, had pluralism as one of the ten core principles of Indian
health systems.
It is essential to increase validation, evidence and research of the different health care
systems practised in our country. It is also essential to reach a common ground where
practitioners of each system of medicine are sensitised and they understand the other
healthcare systems to enable effective care for the patient. There should be an enabling
environment for the practice of different systems of medicine, an enabling regulatory
framework and cross referrals across these systems with increased access to health care
for patients. Health is not just the absence of disease, but also includes physical, mental
and social wellbeing. The Traditional systems of medicine in India includes the social
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component and the cultural context in patient care. More often, in India, People depend
on Traditional medicine for their healthcare needs as it is accessible, affordable,
comprehensible and culturally appropriate.
Literature suggests that, in India, traditional medical disciplines have also been used in
the management of oral diseases. It treats a patient as a whole, not as a group of
individual parts. They are also materials which are readily available to people. But
among them only a negligible percentage of herbal plant extracts are used in routine
clinical dental practice and rest of others are not practised because not much is known
about their efficacy, effectiveness and toxicity. The lack of evidence has been a
challenge to recommend the use of Traditional medicine. Hence efforts should be
focused to encourage research to build evidence for the effective use of Traditional
Medicine.
The Disadvantages of medical pluralism is lack of scientific evidence, concerns about
safety, efficacy and quality of medicines available, lack of updation. These can be
overcome by promoting education, research, scientific evidence and practice of
traditional systems of medicine and having a strong regulatory authority to oversee the
training, research, implementation and production of drugs required for the practice of
traditional medicine.
In a country like India where there are deficiencies in the healthcare system delivery,
traditional systems of Medicine can play an important role. Traditional medicine can
make significant contributions for effective pluralistic health care. If the need to support
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medical pluralism is appreciated and work towards this is initiated, it will be able to
address many healthcare needs of the population.
BIBLIOGRAPHY
1.Rohini Ruhil. Medical Pluralism in India and its Integration into State Health Services
System. AYUSHDHARA, 2015;2(5):309-314.
2.Sanjeevan V, Rajagopal P. Pluralism in Oral Health Care: The Indian Scenario.
International Journal of Science and Research 2020; 9(12): 1411-1415.
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REFLECTIONS:
MODULE
11-
UNIVERSAL
HEALTHCARE
AND
UNIVERSAL HEALTH COVERAGE
Universal health coverage (UHC) means that all people have access to the health
services they need, when and where they need them, without financial hardship. It
includes the full range of essential health services, from health promotion to prevention,
treatment, rehabilitation, and palliative care.
Majority in the world do not receive the health services sought. A lot of people are
pushed into extreme poverty due to out of pocket healthcare expenditure, especially in
India. India's commitment towards achieving UHC is clearly reflected in policies and
institutional mechanisms, which are directed towards increasing coverage and access
to health services. India has launched Ayushman Bharat - one of the most ambitious
health missions ever to achieve UHC. Ayushman Bharat encompasses two
complementary schemes, Health and Wellness Centres and National Health Protection
Scheme. Health and Wellness Centres are envisioned as a foundation of the health
system to provide comprehensive primary care, free essential drugs and diagnostic
services, whereas National Health Protection Scheme is envisaged to provide financial
risk protection to poor and vulnerable families arising out of secondary and tertiary care
hospitalisation to the tune of five lakh rupees per family per year.
The World Health Organization (WHO) has identified four key financing strategies to
achieve UHC - increasing taxation efficiency, increasing government budgets for
health, innovation in financing for health and increasing development assistance for
health. Unfortunately, all of these measures fall beyond the control of Ministries of
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Health (MOH). Measuring progress towards UHC is equally important. The three core
dimensions of UHC proposed by the WHO are “the proportion of a population covered
by existing healthcare systems, the range of healthcare services available to a
population, and the extent of financial risk protection available to local populations”.
In India there are equity concerns with regards to healthcare access and the contribution
of public health expenditure is also low.
Healthcare needs are not only uncertain and unpredictable but also catastrophic to
families living on the margins. Poor and vulnerable families not only spend money outof-pocket (OOP) due to ill health but also have to suffer wage loss to seek healthcare.
One of the reasons for the high rate of OOP expenditures is limited access to
With increased longevity, an epidemiological transition towards non-communicable
diseases such as hypertension, diabetes, mental illnesses and other comorbidities is
inevitable. These conditions require long-term care and are best managed through
comprehensive primary care provided in an outpatient setting. Any health scheme
favouring hospitalization alone over comprehensive outpatient care and coverage may
not be an appropriate product for health needs of the society.
Health indicators have been gradually improving in India, but health for all is yet to be
achieved. “Prevention of diseases” is a more cost-effective strategy than the popular
approach of “Treatment.”
According to experts, Universal Health Coverage requires adequate healthcare
financing and human resources to provide financial protection to the underprivileged
29
by covering their medicine, diagnostics, and service costs. UHC strategies should
enable everyone to access the services that address the most significant causes of
disease and death. Moreover, it should ensure that the quality of those services is good
enough to improve the health of the people who receive them.
REFLECTIONS ON THE DOCUMENTARY SICKO
It was very interesting to watch this documentary. It gives us a birds' eye view into the
different types of Healthcare systems in different countries.
The healthcare system in the US relies basically on Health Insurance. Everyone needs
to have Health Insurance. Not having Health Insurance is catastrophic for people falling
ill or requiring emergency services as healthcare is very expensive. You may or may
not get the healthcare you seek as you may not be able to afford it. Many People lacking
Health Insurance die owing to Non-accessibility and Non-affordability to Healthcare
services. The life of those having Health insurance is no better. You still have to shell
out quite a lot of money out of pocket for health insurance as co-payments, and
deductibles, especially if you are suffering from some chronic illnesses requiring
frequent healthcare services. There is also the possibility that many may not be eligible
for health insurance claims due to pre-existing conditions which may often be the case
for many. Though there is quality healthcare available it is not accessible to a large
number of people. Even those who volunteered their services to the nation and its
people in times of great tragedy were denied healthcare at the expense of the
Government.
30
On the other hand, through this movie, we have been exposed to Non-Profitable
Healthcare services in UK, Cuba and Canada accessible and affordable to all
irrespective of your nationality, financial conditions, age, citizenship, religion, region,
political affiliations or socioeconomic conditions. No matter who you are, whatever
your healthcare problems, you will be able to access and afford healthcare if you are in
these Nations. The true essence of the Right to Health and Universal healthcare is
realised. Available medicines at a basic cost if you can afford it and arrangements to
provide medicines for free if you cannot afford it, is what was observed. Quality
healthcare services were provided free of cost which would not otherwise be afforded
by many. We could also see how Health-Related Quality of Life was also given priority.
Every nation must strive together to achieve Universal health care.
BIBLIOGRAPHY
1. https://www.who.int/health-topics/universal-health-coverage#tab=tab_3
2. Zodpey, Sanjay, Farooqui, Habib Hasan. Universal Health Coverage in India: Progress
achieved & the way forward. Indian Journal of Medical Research: April 2018 - Volume
147 - Issue 4 - p 327-329 doi: 10.4103/ijmr.IJMR_616_18
3. Kumar R. Achieving Universal Health Coverage in India: The Need for Multisectoral
Public Health Action. Indian J Community Med. 2020 Jan-Mar;45(1):1-2. doi:
10.4103/ijcm.IJCM_61_19. PMID: 32029973; PMCID: PMC6985948.
4. Shroff ZC, Marten R, Ghaffar A, et alOn the path to Universal Health Coverage:
aligning ongoing health systems reforms in IndiaBMJ Global Health 2020;5:e003801.
5. https://swachhindia.ndtv.com/world-health-day-2021-universal-health-coverage-inindia-is-still-a-long-way-to-go-say-experts-58104/
31
4. REFLECTIONS ON USE OF THE LMS, VIDEOS AND PARTICIPATION IN
LIVE ONLINE SESSIONS.
The Learning Management System was very user friendly. Initially it was web based.
Later, to help us to access it in our mobile devices, an app interface was used. This
initiative from SOCHARA was well appreciated because we could access the LMS at
our convenience. The LMS comprised of various modules with learning materials
being uploaded on time, a few days before the live sessions. This was done to help
facilitate more productive discussions during live sessions. The learning materials in
each of the modules had videos, reading materials, and the recorded videos of the live
sessions for the benefit of those who have missed out on the live sessions. Most of the
live sessions were quite engaging and interactive.
5. HOW WAS A BALANCE BETWEEN WORK, LIFE AND THE CHLP
MAINTAINED?
It was difficult for me to maintain the balance between work, life and CHLP, due to
certain unanticipated family commitments. The facilitators at CHLP were very
encouraging and helped to keep me motivated in my learning process of CHLP.
6. MENTORSHIP PROCESS AND REFLECTIONS
I had a great mentor in my learning process at CHLP. He has been very encouraging
and has taken the time to discuss and make me understand Community Health Action
Approach. He has helped me to understand its distinction from Public Health
Approach. Through the discussions he has enabled me to orient towards
understanding how empowering the community, to help take action towards their
32
health is more sustainable and effective than any other Top-Down method. He has
also helped me to understand reflective writing.
My Project idea draft was initially not oriented towards the Community Health Action
Approach. Through discussions and communications through mail, he has helped me
to get a better picture of what exactly I need to do for a more sustainable health action
plan. There has been a lag from my side in interacting enough number of times with
my mentor.
7. PROJECT LEARNING EXPERIENCE
My project was on Exploring oral health promotion in Anganwadi Centres. This project
helped me to understand the oral health needs of young children visiting the Anganwadi
centres as perceived by the community and the barriers they face in accessing Oral
health care. I was also able to carry out oral health promotional activities for the
Anganwadi workers and the family members to empower them in taking care of their
children’s oral health. This project has enabled me to partly put community health
approach to practice, though I still believe I have a long way to go in completely
understanding and implementing the same.
8. TAKE AWAY FROM CHLP AND LOOKING AHEAD
I have been able to understand and apply Community health approach which I have
learnt through Community Health Learning Programme.
I have been able to understand the community needs better through this course.
I am hoping to implement Community based health action in future projects taken up
by me in my profession.
33
9. IMPACT OF COVID-19
Covid-19 had a major impact on me. It changed the way I thought, to the way I behaved.
I had only read about discrimination and stigmatization. I did not realize that I would
be a part of expressing discrimination and experiencing stigmatization due to a viral
disease. Though in India, we have many more basic issues bigger than the impact of
Covid-19, for at least 2 years, Covid-19 received all attention. I read stories of how
humanity was all forgotten and also stories of people expressing humaneness even in
their worst times. A complete lockdown, followed by harrowing stories of people
infected or suspected as being infected, being isolated and allowed to die alone for the
benefit of many had a grave psychological impact on me personally. The expenses for
healthcare shelled out by patients towards hospitalisation for Covid-19 shocked me. If
ever me or my dear ones required hospitalisation during the peaks of the pandemic, I
did not know if we could manage to access or afford the overburdened healthcare
facilities.
I lost a grandmother and aunt to Covid-19, where they had to die all alone in a hospital.
In the first lockdown seeing a human being on the road or hearing the doorbell ring
brought me panic. In the second lockdown, hearing the sirens of ambulance brought
fear. Whenever I sat alone, I spent it in feeling depressed about the unpredictable future.
Family life got disrupted as well. It took time for all of us to come out of the isolation
of our homes to being a social being once again. Though things are near normal, I do
realise Covid-19 has left its mark psychologically.
I am Public Health Dentist, working as a faculty in the Dental Institute. For nearly two
years’ student learning was impacted, as majority of the learning was online. Theory
could somehow be managed. Virtual or Online learning, definitely could not be a
34
replacement for clinical learning. The staff salary of our institute was also impacted.
For half a year, both teaching and non-teaching faculty of our institute worked for half
the salary. Patient care was compromised, as all public health activities carried out in
the form of outreach programs had to come to a standstill due to the rules of lockdown.
Patients who started visiting for their oral health care had to bear additional expenses
for the PPE to be worn by the Doctors. Things on the professional front has now
recovered.
Prior to Covid-19, I would never have preferred to learn anything online, as I strongly
believed that face-to-face learning was the best form. Covid-19 has changed that
thought process for me. I was able to join CHLP as they offered the course online, when
it was most required. CHLP has managed to make online learning as engaging as
possible, with interactive online sessions and user friendly Learning Management
system.
35
PART- B
COMMUNITY-BASED HEALTH ACTION-REFLECTION PROJECT
TITLE
EXPLORING ORAL HEALTH PROMOTION IN ANGANWADI CENTRES
BACKGROUND
The Integrated Child Development Scheme (ICDS) is a comprehensive and
multidimensional program in India especially for young children for their early
childhood development.1 Services are delivered at community levels for children below
six years of age, pregnant women and nursing mothers. It provides services like, preschool formal education, health education, supplementary nutrition, referral services,
immunization and health check-ups.1,2,3,4,5 The Anganwadi workers have regular
trainings on behaviour change communication and capacity building strategies along
with health education.2 The Anganwadi centres face lot of issues such as unlimited
duties for Anganwadi workers, lack of community involvement and participation,
irregular supervision and lack of competitive salaries.6
RATIONALE FOR THE PROPOSED PROJECT
Oral diseases like dental caries are serious public health problems especially among
young children, which affect their overall health and quality of life.1,2,3,5 The lack of
available and affordable oral health services results in worsening of the oral health
problems, and also increases the cost of treatment and care.1,2,3 As the oral health and
oral health behaviors of the child is set in the pre-school period, orientation of the
36
parents and family towards preventing dental disease and developing good oral health
behaviors among their young children around this age, will be helpful in determining
the person's oral health for many years to come.1,2,5 Anganwadi workers are grass root
workers responsible for early childhood education, development, health and wellbeing.1,2,3,4 Educating and Empowering them and the communities they serve helps to
provide oral health promotion to the community.1,3,4,5
The Operational Guidelines for Oral Health Care at Health and Wellness Centres given
by the Ministry of Health and Family welfare states that Oral Health is an Integral part
of General Health. The ASHA workers and Multipurpose workers must Co-ordinate
with Anganwadis for ensuring daily tooth brushing among children by incorporating a
toothbrushing rhyme/jingle in pre-school teaching at Anganwadi centres. The Dental
Assistant/Hygienist must also coordinate with Anganwadis and must provide oral
health education and preventive demonstrations wherever possible. Platforms such as
Anganwadi centres should be utilized for conducting health promotion activities with
regards to oral healthcare.7 Thus the Anganwadis can play a major role in oral health
promotion of children.
37
GOAL AND OBJECTIVES
Project Goal:
Promote Oral health among children attending Anganwadi Centres.
Project Objective:
● To understand the barriers faced by Anganwadi workers and the communities
in promoting early childhood oral health.
● To understand the determinants for Early Childhood Oral Health.
● To empower the Anganwadi workers and Communities towards promotion of
oral health of young children
DESCRIPTION OF THE IMPLEMENTATION OF THIS PROJECT
Five Anganwadi Centres were involved in the implementation of this project.
Mapping of stakeholders involved was carried out by having a discussion with the
Anganwadi workers.
Discussions were carried out among the Anganwadi Supervisors, Anganwadi workers
and with family members of children attending the Anganwadis to identify the felt
needs in terms of children’s oral health.
Discussions were carried out to discuss the oral health needs of young children, possible
solutions to address the oral health issues.
Oral health Promotion of children was carried out with active involvement of family
members and Anganwadi workers. Oral health awareness sessions were carried out for
the parents and Anganwadi workers. IEC material on oral health promotion in the form
of flipcharts and posters were provided to the Anganwadi centres. Discussion was held
38
with Anganwadi workers and family members to understand the barriers faced by them
in accessing oral health care for children. Oral health screening was carried out for the
children, family members and Anganwadi workers to help the community realize the
normative needs. Referral for Treatment was provided to the Dental Institute.
PRINCIPLES
OF
COMMUNITY
HEALTH
ACTION
ADDRESSED BY THIS PROJECT:
● Axioms of Community Health
Axiom 2: Autonomy over health
Axiom 3: Integration of health and development activities
Axiom 5: Empowerment of the community
THEMATIC AREAS OF THIS PROJECT:
● CHILDREN’S ORAL HEALTH
39
APPROACH
COMMUNITY BASED ACTION
INITIAL VISIT TO ANGANWADI CENTRES
DISCUSSION WITH ANGANWADI WORKERS,
SUPERVISORS AND FAMILY MEMBERS OF CHILDREN
IDENTIFYING CHILDREN'S ORAL HEALTH RELATED
FELT NEEDS THROUGH DISCUSSION
ORAL HEALTH PROMOTION OF CHILDREN WITH
ACTIVE INVOLVEMENT OF FAMILY MEMBERS AND
ANGANWADI WORKERS
UTILIZATION OF ORAL HEALTHCARE BY THE
CHILDREN AND ALSO BY SOME OF THE FAMILY
MEMBERS
IMPACT OF THE COMMUNITY HEALTH ACTION
It was observed that lot of parents utilised the oral healthcare services for themselves
as well as for their children. Some of the parents even got into an active discussion on
the oral hygiene care products, that should be utilised for their children, implying their
concern regarding early childhood oral health. Anganwadi Supervisor of one of the
Anganwadi centre, suggested that we should extend the oral health promotional
activities to other Anganwadi Centres coming under her supervision.
LEARNING AND REFLECTION
This project was carried out for a period of three months and I have been able to
involve 5 Anganwadi Centres, during this period.
40
I had conversations with Anganwadi Supervisors, Anganwadi workers and Family
members to understand the oral health needs of children as perceived by the
community, their understanding of early childhood oral health and the barriers faced
in accessing oral healthcare for children.
My reflections from each of the Anganwadi centres are presented below.
Anganwadi centre 1:
The Anganwadi teacher is a resident of the same area. The Assistant comes from a place
close by. I also met the Supervisor. She is the supervisor for around 25 Anganwadi
centres in the area. She also had additional incharge duty of Supervising Anganwadi
centres in another area. There are 25 students in the Anganwadi. There is a room for
teaching the students which looks adequate for 25 students, room for cooking and
storing food and a toilet.
They receive water supply from corporation and there is a tank for storing. They receive
food materials on time delivered to the centre and have enough teaching materials. The
children usually eat at around 11:30 AM at the Anganwadi centre and leave to their
homes by afternoon.
When I visited the centre, some kids, the teacher and the helper were already there. The
supervisor also reached there. At around 11:30AM the children were served a dish made
from green gram to eat and milk to drink. The children's height and weight were also
being assessed on the same day.
41
The Anganwadi supervisor also opined that most of the parents didn't want to cause
distress or pain to their children in the name of Dental treatment. She also wanted
similar programs in other Anganwadi centres that she supervises.
Anganwadi Centre 2:
The Anganwadi teacher travels every day from Pakshikere to Mullakad (around 20
kms). She has an assistant. There are 13 students in Anganwadi. There is a room for
teaching the students which looks adequate for 13 students, room for cooking and
storing food and a toilet.
They receive water supply from corporation and there is a tank for storing. They
receive food materials on time delivered to the centre and have enough teaching
materials. The children usually eat at around 11:00 AM at the Anganwadi centre and
leave to their homes by afternoon.
When I visited the centre, some kids and the helper were already there. As the
Anganwadi Teacher had to visit another centre for some administrative purpose and
since she had to travel from far, she was a little late. At around 11AM the children
were served a dish made from green gram to eat and milk to drink. Among the family
members present, a Father of a child stayed through the entire day at the centre and he
knew each and every child and their family background.
There was one child who used to brush his teeth twice daily. His mother said that the
child insists on brushing his teeth in the morning before he eats anything and he never
goes to sleep without brushing his teeth. The reason for this good behaviour is that, he
42
has an elder brother who follows the same routine. The father of the child insists on
good oral health behaviors for the children. In the mother's words "My husband doesn't
allow the children to sleep without brushing their teeth". The importance placed by the
father towards good oral hygiene behaviors are reflected in the children. The child had
good oral health, with no sign of Dental disease in his primary dentition.
In this Anganwadi centre, during the oral health screening, it was observed that one of
the mother had significant pallor, indicative of anemia. I bought it to the notice of the
mother. She said her haemoglobin was very low. She was not undergoing treatment for
the same, though she did not express the reasons for the same. I suggested her to visit
the nearest Primary health Centre or the Urban Training Health Centre of our Institute,
whichever was convenient to her. Even the Anganwadi worker encouraged her to visit
the health centre.
I also noticed a very young girl, who said she was 18 years old, but she was a mother
of three kids. She stayed with the kids at the Anganwadi Centre and also ate a little of
the children’s food. She was from another district, who has shifted with her husband to
Mangalore recently. Her husband has shifted here in search of work.
Anganwadi Centre-3:
The Anganwadi Teacher travels every day from Tannirbhavi to Marakada (around 11
kms), where her Anganwadi is situated using her two wheeler. She has an assistant.
There are 30 students registered in the Anganwadi Centre and she usually has an
average attendance of 22-25 students. There is a room for teaching the students, room
for cooking and storing food and a toilet.
43
The room for teaching students looks small for 30 students. They receive water supply
from corporation. They receive food materials on time, which are delivered to the
centre and they have enough teaching materials. It appears that there is no appropriate
space to place the teaching materials. The children usually have lunch at the
Anganwadi centre and leave by 2pm to their homes, though the Anganwadi Teacher
and helper have to work till 4 pm. Previously the Pregnant women used to visit the
Anganwadi centre for prepared lunch. The Anganwadi Teacher said that, currently
they need to make home visits in the afternoon. They have to deliver food materials to
Pregnant women and new mothers.
The day I visited the centre, the Anganwadi Teacher was busy with work as she was
getting the Aadhaar details of parents and community members for registration to
Ayushman Bharath. The helper had to leave for a meeting. Hence the children left to
home early on the day of our visit, as there was no food provided on that particular
day to the children, as the Anganwadi Teacher had extra work and the helper also had
to attend a meeting. It shows that the Anganwadi workers are burdened with lot of
work.
The Anganwadi Teacher also said that most of them did not know the importance of
maintaining good oral health in early childhood, especially deciduous teeth. She said
that it is not just teeth, it is also difficult to convince some parents to get their child
immunized on time as they did not want to cause unnecessary pain or suffering for the
child.
44
Anganwadi Centres 4 and 5:
I met the Anganwadi workers and family members and children of two Anganwadi
centres, which were close to each other. One Anganwadi centre had 20 children, another
had 30 students. Both centres had adequate space for children, cooking, stores and
toilet. One was functioning in a rented premise. They were getting food materials on
time. They give eggs, boiled green gram and milk to kids. Many were children of daily
wage workers and maids. The parents of the children often didn't have time to cater to
their oral health needs due to their work priority. They often used to drop the kids to
Anganwadis so that they could go about their everyday work without worrying about
the children.
Reflections and Activities common to all Anganwadi Centres:
At all the Anganwadi centres, it was observed that the parents or grandparents reached
the Centres at different time periods, though the Anganwadi Teacher had asked them
all to come at the same time. This was owing to their family and work commitments.
I met the family members of the children, Anganwadi Supervisor, the Anganwadi
Teacher and the helper.
I discussed with the family members regarding their children's oral health. Majority of
them were brushing their children's teeth once daily. Most of the children were used to
having sugary drinks, sweet and sticky food especially chocolates, in between meals.
None of the parents had taken their children for a dental check-up as they felt oral health
was not a priority especially for milk teeth as these teeth will eventually fall off and
new teeth will replace them.
45
The importance of maintaining the children's oral health was explained to the family
members and Anganwadi workers using an educational flipchart/poster prepared by me
in the local language. There were mothers, fathers and some grandparents present. The
role of family in promoting the oral health of the child was discussed. How certain
Preventive behaviors and simple screening by parents could help prevent and control
dental caries was explained. Some of the parents discussed about the oral hygiene aids
that needs to be used for their children.
Oral health screening was carried out for the child and the family member present.
Referral was provided to the Dental Institute for further care. The Anganwadi Teacher
and the family members were taught to identify the early signs of Dental caries in
children for early treatment.
The flipchart/Poster on Early childhood oral health promotion was given to the
Anganwadi Teacher for her reference and for her to provide information to family
members of the children.
Barriers faced
•
Oral health was not a priority for many
•
Lack of Importance to Primary dentition (Milk teeth) as they exfoliate and get
replaced with permanent teeth
•
Lack of time due to work and family commitments
•
Lack of time among the Anganwadi workers to give priority to oral health
promotion due to multiple work responsibilities.
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PHOTOGRAPHS
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48
49
50
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Philip
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31866708; PMCID: PMC6898873.
3. Raj, S., Goel, S., Sharma, V.L. et al. Short-term impact of oral hygiene training package
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https://nhsrcindia.org/sites/default/files/202106/Operational%20Guidelines%20for%20Oral%20Health%20Care%20at%20HWCs
%202020.pdf
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