FRCH NEWSLETTER VOL.10-No. 1-6-JAN - DECEMBER-1996.pdf
Media
- extracted text
-
P0
6RAR
3
for Research in
Health
NEWSLETTER
rc
For Private Circulation Only
Community
Jan. - Feb. 1996
Vol. X, No.1
Personality Development Programme
One of the main objectives of a project undertaken by FRCH at Dahisar ( a slum settlement in Bombay)
was to train women from within the slum community as health workers. Usha Kumari Kumbla -overviews
a personality development workshop conducted for these health workers.
Though the first batch of women health workers had
reason for choosing such a venue was to enable the participants
completed their training and were set to function as health
to get away from household distractions and to make the
workers in their conununity, they had hardly had any exposure
experience pleasurable.
to their work environment and were not too confident about
managing their role as health functionaries. Also, they would
The resource person for the day was Ms. Aruna Tavde and
now have to manage their job responsibilities along with their
she focussed the session on self awareness, role clarity,
household work which called for a great
identifying barriers in personality development and ways to
deal of lime
overcome them.
management. Given this background, we invited Avehi, an
organisation which 'imparts such workshops, to conduct a
.
personality development programme for both the trained and
trainee health workers.
outside is to give us some direction”; “To develop ourselves”;
“To get to know ourseleves better” etc.
The programme was held for the whole day on Sunday the
5th March, 1995 followed by two half-day sessions on
To clear their misconceptions, firstly, through an exercise
subsequent Thursdays. Altogether, 10 women attended the
they were given to understand that the direction has to come
session from both the previous and present batches.
from within and for this one needed to explore from within.
The main objectives of the workshop were :
The participants were asked to sit quiet for five minutes and
listen to the various sounds around them and then share their
1. To create awaress and help them to accept their own
reflections with the group. The participants reported that they
uniqueness and that of others including their strengths and
heard birds singing, leaves rustling, footsteps of people,
limitations.
2.
When the participants were asked what they expected from
the session their answers were vague like : “Someone from
vehicles moving etc. The first lesson on self
To bring clarification to their role as
In this Issue
heal til workers.
3.
To develop assertiveness in them and
teach them communication skills.
• Personality Development
Usha Kumari Kumbla
•i Environmental Education-------- 5
The first full-day session was held in the
‘ From the Sr Librarian’s Dek------ 7
Dahisar Project.
open and yet failed to notice so many things
around us, we failed to know ourselves really
well. Therefore, as a first step we needed to
take a closer look at our own selves.
Sriniwas Indttpurkaf
open atmosphere of Borivli National Park. The
Usha Kumari Kumbla is a social worker
and was working as a researcher on the
exploration was that, just as we kept our eyes
4 Jankan:UnnatkilahelSidhi
( Article in Hindi )----- -----------8
Vrunda
.
The subsequent excersise continued the
self exploration process. Participants were
asked to close their eyes for five minutes and
think of the most pleasant experience they
had had, relive it, then go around alone, touch the things they
participants strolled as far as they could go, some climbed the
came across in nature and later share the experience with the
tree without any assistance, to the amazement of the picnickers
group. While some of them wandered around as though they
around ! This is what they had to say about their experience:
were in their own familiar surroundings, others were busy
exploring things in nature as though they were noticing them
- “I felt that I could do something in spite of the limitations
and obstacles.”
for the first time.
- “I learnt to trust others (facilitators) who cautioned us
While some of them* were exploring a tree, the facilitator
encouraged them to climb it if they wanted to. To the amazement
of the onlookers, four of them did climb the tree. Later when
they shared their experience, the facilitator explained to them
that the act ofclimbing the tree implied their readiness to take
the risk to explore themselves, and only if we took risks could
against falling or knocking.”
- “I felt a surge of self confidence when I climbed the tree
blind folded.”
- “I think we need to have a goal and respect for what we
are doing, then we can do it better.”
we gain. She continued that many a time, women, tied down as
they are with
marriage, motherhood and household
responsibilities, felt as though their life was like a tree being
cut while branching out. The participants were reassured that
even though the branches were cut, the root was intact and one
still had the capacity to branch out again !
In the next session, the group was divided into three sub
groups and each group was asked to present one of the roles
that they carried out in their daily life. The first group enacted
the role of a housewife - the daily drudgery, the demanding
husband and children, and yet how she found time to attend
the weekly classes on health education. The theme that
As the women shared their experiences, a map was drawn
to denote their world as seen by them. As this was being done,
emerged was that it was the woman’s responsibility to run the
house; she had no alternative but to adjust!
women got to know their world and how they relate to it.
Initially, the women were hesitant to share their experience as
The second group presented the dual role a woman plays -
they felt their feelings were too private to be made public. But
that of a wife and of a daughter-in-law. How she had to put up
once the process of sharing began, they realised that they had
with her in-laws harassment and indifference from her
much in common and could in fact gain from others
husband and neighbours. The message they conveyed was
experiences. In the process they also got to realise their own
that in spite of doing so much, a woman was still considered
potential, hidden talents etc. For instance, one participant
a nobody!
shared her experience in a most poetical way, revealing a poet
hidden in her.
In the next exercise, participants were divided into two
groups and were asked to enact their experience during the
earlier exploration exercise. While one group presented itself
as a shade giving tree, the other acted as a temple for the faithful.
When the first group did their presentation, the second group
got some new ideas and improvised their presentation
accordingly. When asked to share their experience, they said:
- "We learnt to listen to others, bring together each others
ideas and prepare a theme."
The third group enacted the role of the woman as a health
worker. They conveyed that it was a tough job. If they genuienly
wanted to bring about change, they had to work hard. People
don’t easily understand the importance of health, they had to
be visited and talked to again and again, only then could the
message be got across.
I
Through the role plays, women were taught to think loudly
clarifying and compartmentalising the different roles they
played in their daily life. It was also an opportunity for the
women to quantify the effort they put in to run the family which
rarely got noticed. They realised their worth in their family
and also as health workers.
-
"We realised we could not do everything alone. We
needed to give and take."
The day's session ended with a game, after which two
groups were formed. Each group was asked to prepare a slogan
The post lunch session started with an exercise to build self
and chant it aloud. The slogan prepared by the first group was:
confidence and shed inhibitions. Participants were blind folded
and were asked to move around for 15 minutes with facilitators.
Hum Milke Rahenge
Hum Milke Chalenge
When they were observed without their knowledge, their
spirit and enthusiasm was overwhelming. While some
FRCH NEWSLETTER, VOL X, NO. 1, JAN.-FEB. 96
Koi Bhi Ho Toofan
Hum kabhi Na Darenge
2
The slogan prepared by the second group was:
Hum Auroton Ka Nara Hai
relationships etc.
- some issues were considered taboo like talking about
Sara Desk Hamara Hai
sex, sex organs, sexual relationships etc. We have to learn to
Ghar Se Nikal ke Aye Hai
view and talk about them objectively.
Khushiya Yanha Manayenge
Naye Phool Khilayenge
Duniya Ko Dikhayenge
- since everyone thinks and interprets differently, other
viewpoints can also be correct. We need to listen and respect
others views.
Even though the day started with a vague note, by the end of
the day it was obvious that the participants had surely taken a
step ahead towards self awareness and role clarity while
building self confidence and shedding some of their inhibitions.
The result can best be elucidated through the replies given by
some of the participants when asked what they felt about die
day's experience :
In the next communication exercise, participants were
grouped into couples and each couple was numbered one and
Iwo respectively. All participants numbered one were asked to
speak (anything) to those numbered two while the latter were
asked to listen quietly. The same exercise was repealed vice
versa.. Through this exercise, the facilitator explained that to
be effective, communication, had to be both ways. One way
- "I totally forgot about my home and responsibilities and
realised that I have the capacity to do something more.”
- "I realised my potential.”
communication could not elicit a good response. We must
allow others to speak and equally listen to others when they
are speaking. Generally we find it easier to talk than to listen.
Therefore, one must cultivate the habit of listening.
- "I can do anything.”
- “I liked it I never thought I could climb a tree at this age.”
Many a time, the kind of response we received depended
on the way we communicated. For eg. if a woman wanted her
- “I feel happy to know that I have some potential.”
husband to support her role as a health worker, much depended
- “How much I would have missed, had I stayed at home”
on how she would put it across to him. With the help of a
dialogue demonstration the facilitator showed that if you were
The second session was held on 5th March at the
timid, the oilier person tended to take you lightly and brushed
Community Office by Dr. Uma Pocha, Director of Avehi.
off your proposal. So if the worker put across her viewpoint
Before starting the session, she recapitulated the previous
assertively and confidently, she was more likely to get her
session and explained its relevance to die theme of her session
husband's respect and a positive reply. The same principle would
- heal di communication.
apply when she would work as a health worker.
To begin with, she displayed two charts - each showing a
Further, she talked about how we could use audio-visual
red dot stuck on a white surface in black background. In one
aids to effectively convey the message we wanted to. Since
chart the red dot was in the center and in the second chart it
what we saw and listened to created a more lasting impression,
was on the left hand side bottom.
what was demonstrated in the form of diagrams, charts, role
plays etc. played an important role. Also, it was necessary to
be aware of the way we talked and the tone we used. Some
times we needed to step into the oilier persons shoes and try
to think about what was going on in her/his mind. For eg. when
the facilitator realised that the participants harboured some
myths regarding family planning (FP), she went on to clear
The facilitator asked the participants a few questions like
these myths with the help of diagrams of both male and female
description of the charts and what they meant to them. Based
anatomy and the process of FP operation. She said that we
on their answers, she interpreted that :
-
different people see and interpret the same thing
differently
needed to encourage men to go for FP because it was much
easier and less complicated. She initiated a dialogue to
demonstrate how to convince a couple to go for a small family
in spile of initial resistance.
-
we lend to have a fixed notion about a man-woman
relationship. All man-woman relationships need not be sexual.
Dr. Pocha stressed that while using flash cards as a medium,
They could be father-daughter, mother-son, brother-sister
instead of explaining what was shown and written, we must
3
FRCH NEWSLETTER. VOL X. NO.1, JAN.-FEB. ‘96
encourage participation from the people and build a story based
teaching aids like charts, flash cards, models, puppets etc. which
on it and then fill in the information whenever needed. The
were prepared from waste material like old files, shoe boxes,
story could be different with different audiences as long as the
rags etc. When accompanied with dialogue or songs, these
information remained the same.
teaching aids can become effective media of communication.
He said that one need not be an expert to prepare teaching aids,
Some very interesting questions were raised during the
but we must be clear about the message we wish to convey.
discussion following the above demonstration:
After this session the group was divided into four subgroups.
Each group was asked to choose a theme and present it with
- " When a female undergoes FP operation, the egg does
the aid of any one media demonstrated to them.
not get released into the fallopian tube. Then where does that
egg go?"
- " How does the woman get her periods after undergoing
an FP operation?"
- " How do some women get pregnant even after undergoing
an FP operation?"
The first group presented a poster on ‘Clean Environment
and its effect on Health*. One representative of the team
explained the matter depicted on the chart. The second group
talked about balanced diet with the help of a set of flash cards.
The third group prepared a role play conveyed through puppets,
family planning being its theme. The fourth group performed a
- " Which operation was better - Durbeenwala
role play on malaria.
(Laproscopic) or conventional?"
All their questions were satisfactorily answered by the
resource person.
Each group presentation was followed by a critical •
evaluation from other participants and the facilitator which
helped the next group to perform better. From the above
exercise, the participants were able to learn that:
Dr. Pocha concluded the session by giving them the
It is important to talk with confidence. When someone asks
following set of clues with the help of which health education
-
could be conveyed more effectively ( She called it the first
questions we must not loose our confidence.
barakhadi) :
- We must not use concepts which the lay person finds difficult
- What do I want to convey ?
to understand, for eg. ‘protein*. Instead we must use day-to-
day words which are easily understood.
-To Whom?
-
- Where (place) ?
- How ?
Building rapport with the audience helps to convey the
message better.
-
We must look at the direction of the audience while talking
-When?
or performing role plays.
Dr. Pocha’s session was immensely enjoyed by the
-
While using puppets : the voice must be loud and clear;
participants because she herself was full of vitality and had the
puppets must be seen clearly; when one puppet is talking the w
ability to extract the best from her participants.
other puppet must look at the talking puppet; there has to be
The third and final session was on preparation of low cost
teaching material. the resource person for the day was Mr.
puppets.
coordination between dialogue and the movement of the
Kate Babu and Ms. Taramati accompanied by Dr. Uma Pocha.
Even though puppets are not used very often, when used
properly, they can be a powerful media of communication.
Mr. Babu began the session by saying that teaching aids, if
The resource team demonstrated the use of puppets on the theme
used effectively, could convey the message better than simply
‘garbage management* which was appreciated by the participants.
talking to the group. We could use waste material to .prepare
attractive teaching aids without any extra cost. Besides,
according to him, we did not need to go for elaborate material.
If we are imaginative and alert, we cou id even initiate discussion
with the help of a dot drawn on a plain paper.
The practical experience in making and handling teaching
aids immensely helped the participants in building confidence.
In fact the participants wanted to learn how to make puppets.
Because of time constraints this could not be done. However,
it was decided that the group would meet again on a later date
Mr. Babu demonstrated to the participants some of the
FRCH NEWSLETTER. VOL X. NO.1. JAN.-FEB. ’96
( Continued on pg. 7 )
4
The Right Approach to Teaching
Environmental Education
Shriniwas Indapurkar
Environmental education is gaining increasing importance
rains down on earth on coming in contact with cold air. On
in our formal education system. The constituents of the
being questioned the students quickly gave us all the formal
environmental system, their relation to and differences with
answers. But when we delved deeper and encouraged the
the human species etc. are now being taught to us right from
students to feel free to clear all their doubts we were questioned
the beginning.
on related issues like why were the clouds shaped as they were ?
Why does the sky otherwise look blue, and in the evening take
Unfortunately, like most other subjects, environment too
on various hues ? Clearing these doubts led to a spontaneous
has been reduced to being just another part of the school
give and take of additional information, giving an added
syllabus to be taught from the examination point of view. Its
dimension to our educational sessions.
teaching has become an indoor exercise with no special
attempts to relate what is being taught in class to die actual
. Environmental education becomes more effective the more
environmental surroundings and the problems arising therein.
@or instance, if the children are being told dial it is preferable
informally and innovatively it is taught as it helps to establish
a good rapport between the students and the teachers. In. one
to drink boiled water, die teacher should enquire whether the
of die schools where I was teaching, the students would run
children actually follow die practice in their homes, and if not
their own wall magazine, ‘Dhashta Pushta (Hale and Hearty)’
why ? Whether it is feasible for everybody to boil water ? etc.
in which the students would pour out their thoughts, their
Answering such questions makes the children think over the
experiences etc. The magazine also included special features
problems and relate diem to their day-to-day lives and thus get
for die children like crossword puzzles. Overall, it proved to
a clear conception about them. .
be a very effective communication and education media for
the children.
It is important that die teachers develop a dialogue
between themselves and the students rather than .allow it to
The subject can be made more effective and interesting by
remain a one way exercise where the teacher talks and die
encouraging the students to draw, go for picnics, plant saplings
student receives die information passively. The student should
etc. as elaborated below :
feel free to discuss die issue with the teacher and clear any
doubts s/he may have on die subject Obviously, environment
Picnics : It is not necessary to arrange conventional picnics
is a subject to be taught outdoors where the children’s
to far off places dial cost too much. Picnics can be arranged in
knowledge expands through their own observation. Books
die vicinity where the children are encouraged to observe their
should be used only for reference.
own surroundings including plants, animals, nearby
historical places, statues of great leaders put up in the
In our conventional education system, only those students
various squares, the vehicles passing by etc. Similarly, a
do well in examinations who are able to answer the questions
visit can be arranged to a nearby vegetable market where
in a predetermined set pattern. In effect questions concerning
the students are made to observe the various vegetables,
die environment are too subjective and qualitative to be judged
their nutritious value etc. These picnics are educative
according to this set pattern. Instead, the children should be
without being too expensive.
made to see both sides of the problems and discuss and write
upon diem, spontaneously. This is how diey get to learn more.
Songs and stories : The more complicated portions of the
To take pur own experience, while die rain cycle was being
stories, and questioning die children upon these stories. In fact
syllabus can be made easier by converting the same into short
taught to the students, we gave die usual explanation of how
the children themselves come up with their own stories and
water vapour goes up in die air to form clouds and subsequently
songs lull of vivid imagination which simultaneously gives them
a good feeling of having done something creative.
Shriniwas Indapurkar has given lectures on environment at
many institutions including the NMV, Pune and is presently
Supporting activities : It is necessary to conduct various
working as researcher on the SACHETTproject of FRCH.
supporting activities to enhance environmental knowledge.
5
FRCH NEWSLETTER. VOL X, NO.1, JAN.-FEB. 96
( Continued from pg. 5 )
(yoe
ironically. the teachers seem to have only one target - that of
a ax arfae an al s4 ue cil sh MHGcch 3 P-T dd set
completing the portion for examin lations, from which they
ama- az qe faa a I s6 36163U d wIIHhR E) chl ti4e
hardly get any time off for allied activities. But the children*
he Ele t qe fer ee S’ I
•
can be made to do simple activities like growing certain plants
at home and observing various stages of their growth; observing
3140/ s at EH fera tot t a EH H3 aid cast 4
the amount and type of garbage collected in their homes within
fa- aaz ad che Hohd 8 133Hq EHR Uo dis chl g3 I
a period; identifying bio-degradable and other garbage and
36 as a 7fhr a HquaTdd chl -fa a-l ch ft 4eT 341 I
their proportion to each other etc. These activities have the
nex am? ah frn 53 1 4s ne on as a R 2 arto a
advantage that they do not require direct day-to-day supervision
scbedT-T ar 1368 a ch qie RTd E) ch cl?" 323 8ic " dn
by the teachers.
Iaqasa a^rStera^tat to totaa^r^ to
Live models : Usually, the conventional charts, torso etc. are
23 chl frag soar | 34
used to teach about die various human organs. Instead, it would
a afergerknaSIl-ITUST ITedanfoea-qratUTdeIl
be more effective if one of die students is made to stand in
sbaR4H<
front of the class and the various parts of the body are
a sylvid & ar 365 a& sfach w6 J-EIH StHle ch a l
pointed out on die student. Similarly, while talking about
teeth the students can be made to observe and count each
2 & 1 300 ale q'd ad shdl
HdddsidAo'Te
ae qe e3 q se as- 3 WR- artead a aH toa d”
fed cheT l 3h clH 3 di Tid 4 shfl JJR 31c 4 cl
others teeth.
ar 46
Ue del l ail toc TAT 4s Ud den W 34 3licH 3 46 dis chl
Experiments like filtering muddy water can easily be
conducted in die classroom by die teacher or better still by
the students themselves. Instead of simply talking about
pasteurisation, the students can be taken to a nearby dairy and
shown the actual process of pasteurisation.
aethaf a-I 95 tor i a 3 a- Hef fear a afa a gfee «ile{
aH a? aald sii ahl chifT? ch 1
yfere a ar as- 3 tor adzi qfei a ald ch i gfeie 4
aheT fo q* ae ain a als 3 3 far fa "deil 3 as chil
Posters/charts : Children have a natural liking and flare
a at fern kc gfere se an at to St arfto tot aS i
for drawing. This can be used to advantage by getting die
gfer aa ellchx if als thae ae g3 i
children to make various posters on environment and exhibiting
suc al os I aaf ato to to
them so that it encourages die students’ talent as well as allows
them to gain a deeper insight into environmental issues. This
increases die participation of the children in die whole learning
i
ana fa?
st viar St
to i 3q-T qar al-= to E d to aara 4 aaf aqa to a
a3 to a gfere a to r vrraato at at sefe" qsie 4 34 53
to «ITe i goh aR H Qe de aar a al to HHAT ato 61
process. •
•
ferre an tot * i
Various other audio-visual mediums like puppets, charts
etc. loo can be used effectively keeping die local culture and
local needs in mind. Ultimately, it is up to die teacher to ensure
3 U$ at aclezUi d araanft an tlag 34423 ton t 4e aar
«eIe e i to aR to if aar =ele esos Wr an 399" to
maximum participation of die students by making die subject
31142@cel 3 &HHR aid 11 36TE?VI a to ar - deilt 4 to
lively through effective communication and a deeper
ana us at deldt a to 4 vi aaf fcheie & to qe tor aar tot
understanding of their mental framework.
it =1-12 freft e i
•
$8 HoRi afa a araanft an gap tien J94 dfd toto
FREE ABSTRACTING
aa> St chad t i aa-arto a to wareT-B-galeT tof ac ae
The contents of this newsletter may be
sI-chle afto ato i oI-chr to d HIT HH" aee toar tot
abstracted without prior permission.
379IT aal adleafac t i suc (via 29 a SlT-3!‘T HPT a aei
However,
would
appreciate
a rrs Ha ar ton an $6ol St ar 311424c 11 sefet sl-chl?
acknowledgement of the source and
tor aaf a qeef tot t i sad tot to at * 81424chrT t1 R
copies of any abstractions
se tot an E to =8 aca, as if a- i ?-IT arfto I
we
f-4 8rga .* Tfe? ak nhft
FRCH NEWSLETTER. VOL X, NO. 1. JAN.-FEB. *96
—
FROM THE SENIOR LIBRARIAN'S DESK....
New Arrivals in the FRCH Library
1.
Agnihotri. R.C.. Geomedical Environment and Health Care,
1995. Rawat Publications, Jaipur, Pgs. 284.
11. Macleod, Ray and Kumar, Deepak, Technology and the Raj :
Western Technology and Technical Transfers to India, 1700-1947,
1995, Sage Publications, New Delhi, Pgs. 348.
2. Chowdhry, Prem. The Veiled Women: Shifting Gender Equations
in Rural Haryana, 1880-1990. 1994. Oxford University Press,
12. Mathur, Indu and Sharma, Sanjay, Health Hazards, Gender and
Delhi, Pgs. 461.
Society, 1995, Rawat Publications, Jaipur, Pgs. 190*
3. Dahanukar S. and Hazra. Avijit, Heal With Herbs, 1995, CSIR,
13. Mundigo, Axel I Mens' Roles, Sexuality and Reproductive
New Delhi, Pgs. 86.
Health, 1995, MacArthur Foundation, U.S.A., Pgs. 32.
4.
Darby, Phillip. Three Faces of Imperialism : British and'
14.
Nandy, Ashis, Alternative Sciences : Creativity and
American Approaches to Asia and Africa 1870-1970, 1987, Yale
Authenticity in Two Indian Scientists, 1995, Oxford University Press.
University Press, New Haven, Pgs. 267.
Delhi, Pgs. 152.
5. Dhillon. H. S. and Philip. Lois. Health Promotion and Community
Action for Health in Developing Countries, 1994, World Health
15. Pachauri, Saroj, Defining a Reproductive Health Package for
India : A proposed Framework, 1995, The Population Council, New
Organisation, Geneva, Pgs. 122.
Delhi, Pgs. 67.
Palanithurai, G., New Panchayati Raj System : Status and
6. Duggal, K.N.. Elements of Public Health Engineering (4th Ed.),
16.
1995, S. Chand and Co; Ltd., New Delhi, Pgs. 488.
Prospects, 1996, Kanishka Publishers and Distributors, New
Delhi, Pgs. 166.
7. Gillespie, Stuart and McNeill Geraldine. Survival in India and
Developing Countries, 1994. Oxford University Press, Delhi, Pgs. 216.
17.
Roberts, H.A., The Principles and Art of Cure by
Homeopathy : A Modern Textbook, Pratap Medical Publishers Pvt
8. Headrick, D.R.. The tools of Empire: Technology and European
Ltd., New Delhi, Pgs. 285.
Imperialism in the Nineteenth Century, 1981, Oxford University
Press.
18. UNICEF, The Progress of Nations, 1995, 1995, UNICEF, New
York, Pgs. 54.
9. Savita Joshi, Women Workers at the Grassroot Level : A
Sociological Study, 1995, Ashish Publishing House, New
19. Vandana, Shiva, Captive Minds, Captive Lives: Ethics, Ecology
Delhi, Pgs. 179.
and Patents on Life, 1995, Research Foundation for Science,
10. Jussawalla, J.M., Nature’s-Materia Medica : A Handy Guide
Technology and Natural Resource Policy, Dehra Dun, Pgs. 212.
on Prevention and Treatment of Diseases by Rational Methods,
20. WHO, Principles of Nutrition Management in Primary Health
1995. Popular Prakashan, Bombay, Pgs. 376.
Care, 1995, World Health Organisation, New Delhi, Pgs. 43.
( Continued from pg. 4)
and actually practice making puppets.The resource person
stressed that to make die sessions really worthwhile, what was
learnt during the brief period had to be brought into practice
while participants actually undertook health education in the
session as it gave them a lot of opportunity to express
themselves.
While the training session in itself was a unique and helpful
experience, we plan to increase its effectiveness in the
following manner:
community.
1. To incorporate the methodology and communication
The workshop was concluded with a formal evaluation of
all the three sessions during which the participants spoke about
what they gained during the session and what they felt about
the methodology used.
For all the participants it was their first such experience
and they enjoyed it a lot. They specially liked Dr. Uma Pocha’s
7
skills taught during the workshop in the practice sessions in
health education classes and later, in the community.
2. To prepare low cost teaching aids to be used for health
education.
3. To share the knowledge and experience with those women
who could not attend the workshop.
□
FRCH NEWSLETTER, VOL X, NO.1, JAN.-FEB. 96
vIldoi : vaf a usel vlot
N ?x h
5" enki
__
dsT ds
1
9 gu l ale h aer a Sf-I Rqe *19 field 6 "des
3 - chs I6 far l o-chl as A ata a HHeTe d
tidf faa qr wII-chift 58666 a ondf 11 me a a a3 alei
sf mat & fo qc a aiot HAT i GT-I *
a Hd A
sER natst 3 anfecft get RHe 3 85
59
8 fic telT 1 st
selldh a vie qsele a83 3 ferg w cl ng
3-E1
ais an- A qf flcie l 165 eft 8,
4R toar vildI & I as Wu
o t qed Ata a ahTcchef ata a 34c1"I-8T7"T im At qe qee
a- 3 fass Hr 4 B12-sl2t aneyach gfaa * aff ugu 6 l
ei 3 u sl ch serg alf HH qef 11 de *
- H18 Hat A Wea
ch88
" Eld 8 dfeh 3
qsox (ld EIHU a=iot sfafat eft wneft.8 I $8 RT Hfche
Am^arq^jte^titten^Ag^ Asawraqat
a an vim to <4i 'dial % a 363 ar A faazo BIT wild & l
faa-fa «Ct avI-IT, ate, fer anf A faraa a sI-cR?t,
31-vi e 3 H1$ HI-1
se acTe?" a sfer Ek ? to tare ae te fa-Rft d f
ata At RRCR tie (AaiaA, afr tle ahs 3.) Aa aS Aar
tidfan aff Eid ? i s4 84 ? a ATTc cR" 25 alelld tled
A ch! chi ald Rcl afchl? - 36163" a toq dellot, HHHcch
k aq Ue qel t to HTTfG1cF, zvcq, enfach anfe t alei ch
ana, y s4c farar w SHR? A olet t i W2u 89 Iu
qRUIH tar q Eid & l cifh- a8 maar dd wt’e serls ad e
. Aa a TTHT sellct 3a fauay qaf a vild e i Wu qec g-a”
toteto^tir^ A Atitsna A wi
vlldT 8, tor chidchefe ar fi-fis td da tieToi ERT ae Wd
a varmaqnf q?
t i chf sic ERT $8 cim a wa ne sid e i 36TE?"
4140 2-T, zal aic-I a qieef c’leh wind de ch{ 2- i Rclt,
aie
ar HchRt, ad f tad dat He 4 * ye fadR che ale
A sent a-s ‘s atom a (L.R.D. P.) 3 ara fichie tor Tat ?6T
HieT JKT srcid e i farR qsdAT Jeid q8 ? viton agd e
ch fide k ch «il At Ha qils a 344 3JHR ara aA l
su&farrki RT tast gu? Hoi chl fadR Ele ? 4e frs
Wd fichld At ae He e cif-T titqr aS aHT WlcTEld t
qeanTI aonsaer ser fH?tS1chel8 fHn chl chR?"
&1
tdad teA A^aAaitif AteA^nto, afecieftofch-i
nr nA
-an rear At i $ ait A kA ae"T-3le!"T &4H8 tea
g l
aq aa anfch fif d g40 ei 3 ferg agd A avT at a
deilot A c!H A tcf a ara A STR ar qm 6o- arafe
a ahee cbHM W To Ts i 3He I so-ich fog a a I ails ‘is
ar vqe.cich{ aaTAk^aaraaSafqaSto E3-nule & H,
a- ac a uga E qar far =e ad i sufog ^tot Elid A
too ana a toan aa c’ld 6 ar aA ci’d sHol 44- fo i
afac the q6 ftldl i 2Q 4 T4 a JR cl Whitici aedT
MId t I 4881 I JR, a 4 4 atita a aga d TRig UeT
aH- mwr fer a alld 8 i 46 manual fer onfc aa a
& qef afeh trtAK HTHTfich as A. tit frs ad 81 seft
188 * a c 23 3 ofache aRR deld § fer 81
qe aim e to qs a tar cl A farR Hd: Ele t i face
al mar 3 ann d cict 22 ah Ee do q
ae {9 fers
dell k i na uffaf sHo E] ah ahs ci?" 8 3 34H 4 t
to til ald al sl- a dim i aivi-y, chiae, saf c aq WaMT, 21a
af a vl-chl{ J1H el ach ugud 6 ne l qvi-T37 ah wIl-cR3
HERT% A qAte A ate A1 A Aa a Q.BT.ft.q. an
ch% de <T t l ^aq tle A H-H1q Aa aS maanA, ald-lle,
det onfe Aa saf. A feuar ar A SI-hR{t A ^tet t i a®
HfTe" A ft a artit $8 terr A mfaa a ft m ? E :
Aa A af?T" an # HTH-dach (jnaaaiaa an that) A tea
W maanft A at 1 sq adcch ana-ana d naraan a ate 8
56 faya ar quf g i ^aa A v--HH93 AS A toq.aa aA
«I‘d, sechl Her a t, 56 tea ar A naf g3 1
46 maanA tea ar EHR 2 A af A A Uo art (taafchi)
3- ci ao ugud & ae at a « SHcl WhieT ah4 ci i 3PR
A a3 At an w--HHI"I93 fichle- an freq toar i st aac
titnr ac JHcl" ugd at cl
Aara^tof AAimatiam AnanaqaSA AftiqAAatti Ia3
— Ec6 A fog dis Hchn i
sHch? A saf a qee didt t l st fdR d 5.8...
44 AA a s-cl c{ toar An acgdc c6l to chiad A A ^a ana
A toq AA aA A ate A i Heach A che to tor 3-2 JH7743
HIj" RR R7, Hf«IT3I $ fi
.... a ART sd vil-idici
afoTeo a qe as cloHd-llco afT1" an ci aid cid % i
aAtear l tor A a^ art Ad aA ^A Ig*fe-oiaans2fi
(oq YYe)
Edited by Vaijayanti Aphale with assistance from Nagesh Mirajkar. Produced by the Foundation for Research in Community Health, 3-4, Trimiti B Apts,
85 Anand Park. Aundh, Pune - 7. Registered under the Bombay Public Tmst Act Printed at Omega Offset, Maratha Colony, Tilakwadi, Belgaum - 6.
The Foundation for Research in Community Health
For Private Circulation Only
Vol. X, No.2
March - April 1996
A. Cooperative Financing for
Health Care in Rural India
Ae y
' a " SS J
C
O
jX
2 o Je
Compiledfrom the paper presented under the above title by William C. Hsiao
s— o an^ Priti Dave Sen of the Harvard School of Health, Cambridge at the international
X.
seminar on Health Insurance in India held at Bangalore from 20-22 September 1995.
Community-based cooperative health care schemes have
existed for decades and today, cooperative
sometimes inaccessible and often of poor quality. Moreover,
financing/
the services provided by government providers are not free.
organisation of basic health care has sprouted in many low
Often, government clinics and hospitals have a shortage of
income nations. This article explains the basic concept of
drugs and patients have to purchase drugs from private chemists
cooperative health care (CHC) and compares it to other forms
and also pay unofficial fees to government providers. In fact,
of health care delivery.
patients‘ out of pocket payments for government services (Rs.
125) are quiet close to those in the private sector (Rs. 164).
Cooperative Health Care
Where private sector health services are concerned,
To some extent health care is a merit good and recognising
many Indian villages do not have qualified private providers
this the community takes collective action to mobilize the
because of insufficient demand or because market forces failed
cooperation of all its members to finance, organise and manage
.
•
to generate the supply due to information barriers and other
health care. This is the basis of cooperative health care. The
generic form of cooperative financing/organisation of health
care has three distinct features. First, the funds come from
three channels : households, the government and local
industries (tripartite financing). Second, there is an integration
market failures. Consequently, patients often consult local
unqualified practitioners or, alternatively, have to travel long
distances to obtain health care from qualified practitioners. Even
where private services are easily available, many a time, the sheer
cost of the treatment renders them beyond the reach of the average
of financing and delivery of basic health
consumer.
services. And third, the financing and delivery
In this Issue
are organised and managed by the local
• Cooperative Financing for Health :
community (community based and community
managed system). Thus cooperative health care
incorporates two major principles : community
cooperation and self-reliance.
What is the rational for organising CHC
when there are already government and private
health services being provided in the country ?
Public sector provision is under funded,
((46>)
4(6
Care in Rural
Health financing experts often point to
'
William C Hsiao & Priti Dave Sen
• The Reation Between Universal Health
Insumnce and Cost Control--------4
Mark Goldberg, Theodore Marmor
and Joseph White
♦The Coverage of Compulsory Health
Insurance----------------------------
Brian Ahel-Smith
4
'
•F rm the Sr. Librarian’s Desk.........7
• Swasthya Ka VUtiyaPrabandlia^^^
(Artide in Hindi
J
Dr, N.H, Antia
health insurance as the answer to the above
problems, but CHC lakes care of providing
health services in an even better manner than
traditional health insurance due to the
following differences :
1) CHC mobilises tripartite financing and
funds both basic and catastrophic health
services. Thus, unlike in conventional health
insurance which insures only for catastrophic
expenses, cooperative financing allows consumers to budget
on die Board of the centre to direct and supervise its affairs.
in advance for the services they expect to use, regardless of
This board would be accountable back to the community
whether the cost of die service is large or small. The services
members and die government.
covered by CHC are selected based on their cost effectiveness
and people’s willingness to pay.
We have assumed that our hypothetical cooperative covers
15 villages with a population of 1000 in each village. Their is
2) CHC does away with trilateral relationships, brought into
provision for one primary health centre for this total population
play by insurance health plans, by combining together financing,
of 15,000. The primary health centre would be staffed by one
risk-pooling and service delivery thereby keeping intact die vital
doctor, one mid-wife, one clinical nurse, one primary care
bilateral relationship between patientand provider organisation.
practitioner, one pharmacist and one assistant.
3) The fee-for-service payment method or the method of
reimbursing the patient for expenses incurred, both followed
under an insurance scheme, induces practitioners, clinics and
hospitals to provide greater quantities of services and prescribe
more drugs than is really necessary. Cooperative financing does
away with this problem by paying practitioners (such as health
workers, midwives, physicians) on a capitation or salary basis.
More sophisticated practice could add a bonus to die capitation
or salary based on performance.
In addition, a sub-centre is established in each village and
staffed by one full-time equivalent primary care practitioner -
a retrained and certified ancillary health worker who is
competent to deliver preventive services, perform basic
diagnosis and curative services for die 8-10 most common
diseases with the medical competence to give appropriate
injections and drugs, and also treat minor wounds. The sub
centre has a stock of generic drugs specified in an essential
drug list. This worker will be retrained to perform the
4) CHC and insurance plans differ on organisation and
designated functions and will be supervised and monitored by
management of communities. Firstly, CHC is organised and
die medical professionals staffing die primary health centre.
managed by the communities themselves. Secondly, CHC
organises together die preventive, primary and tertiary services
and coordinates them. The services of medical specialists are
also organised and coordinated and made available to patients
when they are needed.
In exchange for an advance payment, CHC promises to
organise and provide health services and drugs when the
consumer needs them. CHC provides preventive services.
immunisation, health promotion, family planning, maternal and
child health and outpatient services to all its members,
In contrast, traditional insurance plans do not manage die
including drugs for which copayment is levied. Patients have
actual provision of health care, thus prevention, primary care
the choice of obtaining free health services at the health posts
and tertiary services are often fragmented and there is no
and primary health centres or from private practitioners. In
coordination among specialists when they render services to
the latter case die health centre will reimburse die patient for
die same patient.
50 percent of her/his costs.
Potential Gains From CHC
Health workers and practitioners are salaried by the
coperative. Tertiary care is provided at die regional centres.
CHC differs from other cooperatives such as milk,
agricultural etc. because illness is uncertain and thus die need
for health care and die payoff from CHC for households is
The cooperative refers patients to these centres and pays a
packaged fee for these services or contracts for tertiary care on
a capitation-payment basis.
uncertain. Hence, diere have to be enough potential personal
gains from CHC to bring people together for collective action.
From the hypothetical model we can conclude that
cooperative financing of health care may offer at least four
In order to analyse what potential gains may be produced,
types of gains to die Indian rural population:
we have constructed a hypothetical health cooperative and
estimated the cost of providing a comprehensive package of
Access : The new organisation comprises one sub-centre per
1000 population and a primary health centre for 15000
basic primary health care services.
population which compares favourably to one sub-centre per
Hypothetical Model
-
A village may not have sufficient number of residents
required for profitable risk pooling, consequently, adjacent
communities may have to be grouped together to form a health
cooperative but each community would have representatives
FRCH NEWSLETTER. VOL X, NO.2, MARCH-APRIL "96
5000 population and one primary health centre for 30,000
population under die existing government programme. Thus
households can reduce dieir travel time and costs’• since the
sub-centre is located in each village.
Quality : The qualifications of providers will be improved
2
through the cooperative at each village as the primary care
workers stalling die sub-centres will be retrained to perform
die designated functions and will be supervised and monitored
by the medical professionals staffing the primary health centre.
The cooperative members would be entitled to use eidier
the community-managed primary health centre or a recognised
vehicle for India to develop a wider spread of CHC.
Though die Government has no direct role to play in CHC
it can support diis health care system in the following manner:
* Legitimize the CHC approach - official encouragement
as given to other cooperatives will certainly help the rapid
development of CHC in India.
private provider with partial reimbursement. Such an
* Government of international donors can facilitate the
introduction of competition by giving die patient a choice of
development of CHC by providing some of the initial capital
providers will induce the health providers to be responsive to
equipment.
the patient's needs and to improve the technical quality of services.
Economic gains : The cooperatives can form associations to
buy drugs and supplies through international lender and
distribute drugs through regional centres. Thus costs would be
reduced because of economies of scale in group practice and
because of absence of monopolistic pricing.
As mentioned earlier, the payment system for medical
professionals under CHC will reduce over-prescribing of
drugs. In addition, essential drug lists can be established to
assure die most cost-effective use of drugs.
* Government can develop human resources needed by
offering training courses for supplying qualified managerial.
financial and health personnel.
* Government can make appropriate regulations to assure
die financial solvency of the cooperatives, prevention of fraud
and monitor the quality and availability of health services.
Of course, field studies are needed to assess whether CHCs
are viable and can produce more benefits than other alternative
ways of financing and organizing health care of its rural
population and to examine die existence and operations of die
panchayats, and evaluate die potential savings that can be
Also, CHC can serve to rationalise health service
generated through an Indian model of CHC. If initial viability
utilisation by developing referral linkages with other providers
of the CHC programmes in India is established, then
in both government mid private sector so dial patients do not go
demonstration projects can be developed to test the organisational
directly for higher level facilities for relatively simple ailments.
form and management that would be most suitable for India. ,
Such a rational use of health servicesand drugs will ensure
significant cost savings.
Editor's Note : In a study on household health expenditure conducted
in Jalgaon, Maharashtra (1987) and Morena & Sagar, Madhya Pradesh
(1990-91) by FRCH it was concluded that:
Another significant gain would be the reduction in poverty
1 Monthly per capita health expenditure was Rs 16. 02 for rural areas
dial is generated by indebtedness due to high medical expenditures
and Rs. 14.25 for urban areas of which rural transport look the major
share of Rs 9.12 and urban only Rs. 5.30.
Feasibility of CHC in India
Fortunately, India has a long history of local self
2 During the reference period of the study (3 mths), loans were taken
for treatment of 1.3% of the illness episodes amounting to a phenomenal
Rs. 1,233.25 per case.
□
government or Panchayati Raj. Since the 73rd amendment to
die Constitution these Panchayati Raj institutions have been
rendered even more powerful with 29 subjects including health
delegated under die purview of local governments. These local
organisations could prove to be a convenient vehicle for
organising and financing health care for die community.
Moreover, some studies have estimated that the health care
of about five percent of die Indian population is already being
Jaoo Arogyacha Gava
The Government of Maharashtra has selected the set
of four books tided “Jaoo Arogyacha Gava " published
by FRCH for distribution to over 700 schools all over
Maharashtra under the “Operation Blackboard” scheme
which provides for, among other tilings, free distribution
of textbooks to government schools in Maharashtra.
served by NGOs. These NGOs have already demonstrated
This set of books was brought out as a part of the
considerable innovativeness with cooperative financing
School Health Education Project implemented by FRCH
approaches. For example, there are successful rural NGOs -
to facilitate teaching basic concepts of health to school
Sewagram, Raigarh Ambikapur Health Association, Voluntary
children. The books have been selected mainly for their
Health Services - that collect prepayment from households
reader-friendly presentation and use of simple language
and organise primary care and some inpatient coverages to
accompanied by attractive illustrations. That the health
these households. The success of these NGOs in financing and
concepts have been interwoven with the day-to-day lives
delivering health care show that the NGOs could be another
3
of the children makes the books highly appealing.
FRCH NEWSLETTER, VOL X. NO.2, MARCH-APRIL ‘96
How Universal Coverage Makes Cost Control Easier
The Relation Between Universal
Health Insurance and Cost Control
Edited version of an article under the above title written by Mark Goldberg, Theodore Marmor and
Joseph White that featured in the 16th March'95 issue of The New England journal of Medicine.
If a nation does not commit itself to controlling the
adding cardiac surgery units, and lithotripters are not likely to
costs of medical care, then those costs will rise there quickly
be found in different hospitals in die same city, each being
(as they have, in the United States). Frequently, the blame for
used only two days a week.
these spiralling costs is put on private health insurance which
gives rise to third-party payment with all its abuses, as
elaborated in die subsequent paragraphs. Medical costs could
be curtailed by abolishing health insurance. But that would
reduce available medical care substantially for all but the
wealthy and devastate any medical care system based on private
insurance. If third-party payment is to be the norm, then the
experience of many countries shows that coverage of all
citizens can be combined with slower growth in costs by
resorting to universal health insurance.
Because they provide medical care for everyone, not
just subgroups of patients, universal systems are able to develop
ways of managing the capacity of the health care system as a
whole where system-wide bargaining and rule making substitute
for individual price bargaining. In coherent programmes of
universal health insurance there is no need for much of the
apparatus with which individual insurers seek and select
customers. Providers and payers engage in one round of
wholesale price negotiations rather than multiple rounds of
retail bargaining. For eg. a standard fee schedule prevents
patients from committing their insurer to pay whatever a
provider charges. If there are any rules about the type or volume
of treatment, providers confront only one set of such rules.
As compared to the alternatives, cost-control methods
used in universal health insurance systems also have many
advantages for providers of care. More of die health funds go
to die care givers, and less to dieir own administrative staffs
or to outside managers and consultants. Also, universal systems .
are able to structure negotiations with die medical profession
in ways that make cost controls more effective and more
evidently fair. They allow an evolution toward stable machinery
for joint decision making, in which die medical profession has
a stake in decisions it helps to make about, for eg, relative
values for fees.
No one should imagine that any effective method of
cost control is loved by all providers. No system is immune to
arguments dial the wrong costs are being controlled. But the
universal systems, because they dear with the system as a whole.
are able to involve providers in cost control in a way that forces
attention to equity among providers. Physicians and hospitals
are paid in predictable ways for the services they provide. There
are few if any worries about charity care (save for illegal aliens,
in some cases). Universal coverage means that doctors know
they will be paid for the work they do.
Consequences of Separating Coverage and Cost Control
Since all payment follows the same (or similar) rules, savings
that result from changing those rules are spread over the entire
To be sure, the uninsured in developed countries like
system. All these differences from the practice of private
die USA with private health insurance receive some services:
insurance reduce administrative costs both for insurers and
just fewer of them, and later. Also, if cost controls were
for providers, thus, reducing overhead costs.
imposed without universality, providers would be expected to
reduce their levels of “free” care; experience in California
In some countries there are funds that market their
supports that expectation. The uninsured - and nearly a quarter
coverage to citizens who believe they get better service by
of the population will be uninsured at some point during a given
paying more, and their funds pay providers more than the
year- would dien be worse off than before. As most voters are
standard rates to provide that service. But in universal systems,
covered by die same payment rules under universal coverage,
providers cannot play payers off against one another,
there is political pressure to ensure dial these rules are
threatening each that unless it pays more the service to its
compatible with good care - in contrast to what happens in the
members will decline relative to the service received by people
United States, where the majority has no stake in how
with different insurers. For eg. hospitals cannot compete by
Medicaid payment rates affect the quality of care. Instead,
FRCH NEWSLETTER, VOL X. NO.2, MARCH-APRIL ‘96
4
Resolution on Social Security for the
Unorganised Sector by the National
Centre for Labour (NCL) - An apex
body of the labour organisations in the
unorganised sector
The Universal Declaration of Human Rights and the
flimsy social security nets are created for the poor in the
United States which are more in the nature of a safety valve.
A universal system faces political pressures to ensure
quality as well as control costs.
The Adequacy of Supply
Even under universal coverage effective care could be
limited by shortages of physicians and facilities in rural and
Covenant of Social, Economic and Cultural rights, to which
urban areas, or by an uneven distribution of medical specialists.
India is a signatory, have declared social security as a basic
Opponents to universal coverage also claim that cost controls
human right. Yet, the unorganised sectors which
with universality would lower die quality of medical care by
constitute 92 per cent of the workforce in India, remain
creating waiting lists for some procedures. But die question
uncovered by any social security provisions such as ESI,
here is whether a different financing system can produce
Maternity Benefit or Provident Fund.
similar services for as less costs. If we take die case of USA
The unorganised sector workers earn incomes which
are often not enough to keep them above the poverty line.
They have to pay medical expenses out of these meagre
incomes. In addition, since they have no security of work,
they loose even those earnings when they fall ill. In cases
of accidents or death of the main earner, the family is often
which has private health insurance and Canada which practices
universal health insurance, both otherwise following similar
medical practices, no one can build a convincing case that
Canada has health care that is inferior overall to that in die
United States, never mind that any American advantage would
be worth the price tag ($250 billion in 1993). Canada has
reduced to destitution. The unorganised workers have to work
comparable life expectancies even for the very old (and, of
even when they are old and disabled as there is no old age
course, the American elderly have national health insurance).
pension or provident fund. Women often work till the last
A wide range of studies of specific applications show
days of pregnancy and start again a few days after child
comparable performance - lower levels of elective surgery
must be balanced against better access to other treatment."
birth as there is no maternity benefit.
Further more, if there is agreement among American health
There are various schemes, governmental and non
governmental. which do provide a limited coverage to the
workers. These include the Beedi Workers Welfare Fund,
Life Insurance Coverage for Agricultural Labourers,
Maternity Benefit Schemes in various States, etc. However,
policy analysts on any issue, it is that the United States has
serious oversupplies of many services, especially surgery. In
some cases, such as cardiac surgery, oversupply threatens die
quality of care. It is possible to provide much the same services
at lower cost with better capacity controls.
these schemes cover only a small percentage of workers
and their scope is very limited, but they do point die way
to the type of coverage required by the unorganised sector
and can be used as a basis for more comprehensive
coverage.
Conclusions
Many forms of regulation can be used to control costs
but there is no system that controls costs through pure
“competing plans”. Competition and regulation are not
The founding convention of die NCL therefore calls
mutually exclusive. Instead of seeking universal coverage as a
* All member organisations to try and develop social
as a change for strategic action to get both die level and the
for:
threat to die quality of care, a coherent system should be viewed
security programs for their members and link them to
distribution of capacity right. As an alternative to fee-for-
similar programmes already existing.
service practice, good health maintenance organizations can
* The national and state governments to set up tripartite
social security funds which would provide a comprehensive
social security cover to workers.
provide lower cost sharing, better coordinated treatment, and,
if their enrollment grows, a strong indication of inadequacies
in the fee-for-service world. If patients prefer health
maintenance organizations, they should grow. Combinations
* Employers, farmers, traders and other sections of
of regulated fee-for-service practice and voluntary health
society which benefit from the labour of the unorganised
maintenance organizations can be evolved as per
sector, to contribute adequate funds for social security
convenience. In general, the issue of die relative incomes
(Contd. on pg. 7)
FRCH NEWSLETTER. VOL X. NO.2, MARCH-APRIL 96
The Coverage of
Compulsory Health Insurance
Extractedfrom the paper presented under the above title by Brian Abel-Smith
of the London School of Economics at the international seminar on Health Insurance
in India held at Bangalore from 20-22 September 1995.
Compulsory schemes generally start with employees in
and Nicaragua. There is theoretically 80-90 percent coverage
the formal sector and their dependents because contributions
in Brazil, though the services are far from being equally
can readily be collected through employers. They can expand
available everywhere. In Costa Rica 86 percent or 2.8 million
to cover the self-employed and those on social security
people are insured including 49 percent of dependents, but die
benefits. pensions or social assistance are brought into die
indigent population is insured by die state - about 15 percent
scheme, often. with tax subsidy.
of the population is covered without having to pay
Developed countries
incomes who are not working. In the remaining Central
contributions. In Chile all are covered except diose widi high
In OECD countries, which have the most mature systems
die trend has been towards universal coverage under national
health insurance as shown in Table 1. below.
American countries, the scheme covers either all salaried
employees or the main groups among them. In 13 Latin
American countries, provision is made for die sell-employed
- compulsorily in four countries and voluntarily in nine. And
in 12 countries domestic servants are covered but compulsorily
Table 1 : The Trend Towards Universal Rights
to Health Care in OECD Countries
in only nine. Dependents are covered in all these countries except
die Domenician republic, Guatemala, Peru, Haiti and Ecuador.
The first three do, however, cover wives for maternity and infants.
1938 New Zealand
1978 Italy
1948 United Kingdom
1979 Portugal
Asia : Apart from Japan, only Korea and Hongkong have
1960 Denmark
1983 Greece
universal coverage with Taiwan planning it. The Korean scheme
1960 Japan
1984 Australia (finally)
which started in 1977 achieved universal coverage in 1989.
1962 Sweden
1994 Switzerland
There are some 400 insurance societies in diree categories -
1969 Canada
"1999 Turkey (planned)
civil servants plus private school employees, industrial workers
1974 Iceland (explicitly)
and community-based schemes for rural workers and die urban
self-employed. In India and die Philippines die schemes cover
all or most of diose widi salaries, at least in larger companies,
The countries without universal coverage are Austria,
but the latter scheme only finances hospital care. In China die
Belgium. France. Luxembourg with 99 percent coverage,
government covers civil servants and students from universities
Germany widi 92 percent, die Netherlands and Turkey with
and colleges: 30 million persons are covered under this
about 50 percent. But the Netherlands provides universal
scheme. Those working in state and collective enterprises are
coverage for long term care, community care and drugs. Turkey
insured by each enterprise’s welfare fund. This scheme covers
is currently planning compulsory coverage of die aged and
140 million people and 60 million dependents. But dependents
disabled (about 15 percent of die population) and of certain
pay half die cost of services. There are cooperative medical
groups of die poor (10 percent of die population). Ireland does
services in rural areas - funds are collected from farmers and
not fit into diis model as all can use die publicly financed
local government. The current scheme covers around 100
inpatient care but only die poorer sections of die population
million. In Thailand die civil servants scheme covers about
can use the government contracted primary care services.
Developing Countries
five million workers in establishments with 10 or more
employees. In neither case are dependents covered. Indonesia
covers nine percent of the population - mainly civil servants
Central America : Nearly all die Caribbean countries attempt
and the armed forces. Vietnam covers civil servants
universal coverage but die provision is entirely paid for by
including those retired, private sector employees and
taxation. In Latin America, there is universal coverage in Cuba
(Contd. on pg 7)
IRCH NEWSLETTER. VOL X. NO.2, MARCH-APRIL ‘96
6
FROM THE SENIOR LIBRARIAN'S DESK....
Health Insurance : Selected References Available in the FRCH Library
1. Krishnan. T.N. (13th April 1996) ‘Hospitalisation Insurance: A
Proposal* Economic and political Weekly. 31. No. 15 : 944-946.
2. Papers Presented at International Workshop on Health Insurance
in India from 20-22 September 1995.I IM. Bangalore (published by
* Hsiao. William C. & Priti Dave Sen. Cooperative Financing for
Health Care in Rural India : 35.
* Krishnamurthy, V. Health and Medical Care in the Plantation
Sector : 52.
Centre for Development Studies. Thiruvanthapuram) :
* Nandakumar A.K. School Health Insurance : The Experience in
* Athmaraman, T.N. The Cost-Effective and Affordable Health
Egypt -A Case Study : 23.
Insurance Scheme - A Profile of Experience of Voluntary
Health Services : 25.
* Pinto. Marcelinne. Perspectives on Medical Insurance and Role
of Private Providers : 13.
* Banerji. Sanjay Dr. Student’s Health Home : A West Bengal
Experience: 73.
* Banerji. Sanjay Dr. The Student Health Scheme : A West Bengal
* Ratnam C.S. Venkata. Health Care for Industrial Employees in
Large Public Private Sector Firms in India : 60.
Experiment: 73.
* Subrahmanya, R.K.A. Employees State Insurance Scheme : 77.
*
Abel-Smith. Brian. Compulsory Health Insurance : 22.
* Vyas. Jayashree & Mirai Chatterjee. Organising Health Insurance
* General Insurance Corporation of India. Bombay. Health Insurance: 23.
(Contd. from pg. 6)
for Women Workers : The SEWA Experience : 28.
Cl
coverage, those that are insured tend to be better off
economically than those who are not covered. The insured
persons under special social protection.
Africa : Egypt covers government employees, private sector
employees, pensioners (who must apply to be eligible),
widowsand all pre-university students numbering around 14.5
million. Only in Alexandria are family members covered and
they must apply to join die scheme. In all, 23.3 million are
insured out of 56.4 million population in 1993. In Algeria
and Tunisia, all those employeed in die formal sector and their
include typically die civil servants and employees in private or
state enterprises. Usually excluded in die early phases of health
insurance development are die farmers and other self-employed
in die rural areas, whose incomes are likely to be lower on
average, though in some of these countries like Thailand and
Indonesia, voluntary community based schemes have been
promoted to cover these groups.
□
(Contd. from pg. 5)
dependents are covered. Compulsory health insurance is least
developed in sub-saharan Africa. Only in Kenya is there a
of providers should be left, as much as possible, to the
scheme widi considerable coverage : die National Hospital
providers diemselves, as should issues related to die allocation
Insurance covers about 11.4 percent of die population (2.1
of care among patients while issues of capacity require more
million employees and their families). In die Cameroon, 60
collective decision making.
percent of the formal workforce are covered by their
dependents. The scheme in Mali covers only 60,000 members,
serves about 250,000 persons and finances less than two
percent of the cost of health services. Government employees
and their families are covered in Burundi and in Ethiopia:
diey obtain health care from government facilities at half
the cost.
Thus in developing countries with less than universal
7
To conclude, the combination of diminishing coverage and
spiraling costs is not some law of nature. It is a disease
inculcated by the prevailing fragmented, partial insurance
systems and worsened by political failure. It can be cured with
effective implementation of universal systems with dieir
advantages of more efficient methods of cost control, some
compensating benefits for providers, and better political support
for controlling costs.
□
FRCH NEWSLETTER. VOL X, NO.2. MARCH-APRIL *96
tq130 ch fariq yes
3ife
si.
an «ft.yer."E.STx/3nT4 *..87. *f teK 3 *e tihd
Hea, tale q, a3 ache &q dolls (vil.s1.91.) apl
t ufazie a 24,000 ais oqar d * sale tdf chkelT 8 1 46
ten a te a&ta Re sferzter afrdse-cF, MiceTTEc si Serie
eITIIafaesi 384 oudHleIl-Ichanert wlsopotrrr"is*7
tenrea eeeqf a 3 «s ct w-yeitsaI a frd ch *R K qT5
z ud d Hae anftcp 8 1 56 ud
H tare q soot
tesite te
nt tche w l $6 ax 4, few R188 hh—4
tor $s wte f adt t wrdft 1
cite feee sgaz as « Ete t l a, taree «
uxeacuIe(=ft.st.ft.)chlchee
aq 8
di-
te
Uh afftcp HFte sir
chh w q ase ted a aief da 8 w deaf Z" ch te
t, fate
a bee qo frer feet A ssaz aa q Ele k, sox "t "
affer sugr t i fed ae ee a sgHd an ERffei n te AT"
te &K 8, c
* an 4 fr-s
af 9154 al- A ante te, Eo?t da * af Nrn ate 3 00
a dhee 34 sfa & f t l ee q 300 oyd sf czsr
oud tr a a wo suret fofa eqeifch tre ^^4 qollef
HIFFII-IT td axo ahee 4 fr-4gy &
9 Mf 6-7R3 k,
auca ate sI ntet %, w te aHI- d nt ? te cft R40
wafer 3THflch dd facnfecr 29 s, s8 sfr cafth 30,000 oud
suar a te a afa an t i stefar ERT tar deri a? 39
f3r3-49q
fa
te Fie k, ten a sdz 8a K, fr3-4sy « 90 sfr
tche aq aw (=fsit) 81 93 sfRi te ate ah ^ht d,
Eo t i 3 aq alE?" d HIh wife? EieT e fa tarte R shy
ufa qq 3 goflaidt 29 arte Re aw an aw q after ft
ng $e te a zifr q&f, afeo ie ce3 chi 81 sfch HBcy"f
te ate, an 1 Hea Rchi da ar, ate vil dr chef
z i
ana? tr dar auee ate 8 l dft-aidt ze a * tert an
te arm n te tqr a aut ahdn HRirb asde da c ter *
TRe a ch fr-Hchl tieei ch 34a 46 aild i
sas achif chisalt a 4HTChl cHT 2 Hohec ch Rhi, sf as
age 9 oo oud
te Bist wI Hebet t l Ueh aed Hchlf tlE da nt, ssaz da
ait Sic aze d Prefer a3 a te fen f^wn war t i
r cheoh 1t, Hqc ft ghart tare T-d d‘
a ad ten s Hchel t i se d 40 oud al" R R id E)
an qf $u an qonid 8 te asd? t1 att chef
afey, ssf w $e tr HHeT3 a 00 d 6o 9fRid HHe1d
ostch ate te t waf Te adaif d ch wI te tle aug
Hchot t l 46 chiH 4 394 8a ch,
d td aSt this HHT te s i HRd d, U$h 3194rb His« ait cl’
teN ou a sforfal rre chidchafe a deAfsche chkafar
che a duis d, te ate ad Rte ad orate 3 aid dt, r
ch Hec ? a ale I wrafc tr ch-a 25 4=4 ?
auk 3 te d slcufc af s 11 ora: nd s fen d Ueh a
cil ZR tad f Hsat
ada d, tI 3 RoR al d sot wI ?
ch" i
qyar % tr 4
d, ahee 3o oud s me" ala ch scid 8, viai R163 aa —
a orw dta ad sord n i
□
(f- ’3F^n<r: re sfeea)
EH? 24 afai sHit a tl vitedi chi T chi c ft
ufa ast ETH" 9 oo oqar chi tr sal vildl s l 544 d cill
1
FREE ABSTRACTING
I
The contents of this newsletter may be
abstracted without prior permission.
$8 tr sazsii ah Ha 24 die as 31tdici 3R Hlschol chicvi
4 tfsce fTe 3R qa W Eid 11 far 11
chHTA ald
qisaz a W afa aft R00 oqqi 4 “ afach ud ten wild I
w sh ahae RT83 aa ac 6 flfd & 1
57
.
(fear, A^lcb q 27, ($.(.37R, Yh
3 ^if^cb ^t. gee a BF551to>
&8* (s-f arf
shd 8 / 93‘ alfe/ s d H*e Blch? drel chief fod, 3H7 2707
RRcl? ar
.aff.ge.
However,
we
would
appreciate
acknowledgement of the source and
copies of any abstractions
31727 rarreq c4d) A ?uR<i 8 /
The views expressed in the articles are those of the
authors and not necessarily those of FRCH
Edited by Vaijayanti Aphale with assistance from Nagesh Mirajkar. Produced by the Foundation for Research in Community Health. 3&4, Trimitl B Apts,
85 Anand Park. Aundh'. Pune - 7. Registered under the Bombay Public Trust AcL Printed at Omega Offset, Maratha Colony. Tilakwadi, Belgaum - 6.
Eor Private Circulation Only
Vol. X, No.3
May-June 1996
The Rockefeller Foundation in India
Establishing Modern Medical Centres
Nikit Dravid and Vaijayanti Aphale overview the contribution of the Rockefeller Foundation to medical
research in India on the basis of information collected in the course of an ongoing FRCH project analysing
the role of this Foundation in the development of public health and medical research in India.
The Rockefeller Foundation was established in 1913 with
developing health unit organisations in rural and semi-rural areas.
a deep concern over the then-existing state of health care the
world over, as it considered ‘good health* to be a primary
Simultaneously, through the years the Rockefeller
ingredient in what its charter called the ‘well being* of the
Foundation made a series of long term grants for the
people. Considering the prevalence of endemic disease at that
development of medical education in India. The Foundation
lime il was a logical conclusion. Its representatives explored
was particularly interested in experiments which could lead to
conditions in many countries and joined with the local
authorities to battle against malaria, hookworm, yellow fever,
the incorporation of the elements of rural medicine into the
traditional medical curriculum.
influenza, tuberculosis and yaws. Simultaneously, research
One effective plan by which this was done was through the
funds were provided to medical schools, departments and
creation of community health centers which could function in
individual investigators to help build up the basic knowledge
the curriculum as leaching units, much as do conventional
upon which effective and efficient medical care must rest.
teaching hospitals and outpatient departments. To overcome
Till 1920, the British colonial medical facilities in India
the practical difficulty of isolation of such centres and make
had a distinct racial and urban bias. Separate provisions were
their functioning effective they were provided with quarters
made on employment and racial grounds, though in some places
where students and staff could live for the assigned period and
non-ollicial Europeans might be allowed access to hospitals
with space and equipment for a modern medical college in a
designed for civil servants. With the entry of the Rockefeller
teaching situation. Chief among the health institutes and rural
foundation in 1920, for the first time a rural
community centres funded by the Foundation are :
health care expansion began in India. The
Foundation
started
preventive
health
programmes in the Madras Presidency in
collaboration with the government and gradually
extended its support for such activities in
Mysore, Travancore, United Provinces and New
Delhi. The focus of their activities was on
In this Issue
♦EstablishingModern Medical
Centres...-.............................................1
Nikit Dravid & Vaijayanti Aphale
♦The International Challenge of
Tuberculosis -. ..--.-..---.--------...-..3
Sanjay Juvekar
♦Local Belief Systems and Practices...5
Nikii Dravid is a Junior Researcher on the
Rockefeller project undertaken at FRCH. Vaijayanti
Aphale is the Editor of FRCH Newsletter
Seema Deodhar & Aarti Kelkar
♦ Swasthya Scvaon Ka Dhancha
(Article in Hindi
Dr. N.H. Antia
6
All India School of Hygiene and Public
Health, Calcutta
During 1927 and 1928 an extensive
survey was made of medical institutions and
conditions in medical education throughout
India. There was a great need for higher
training of personnel for more responsible
positions connected with teaching hygiene and
administration of public health in India.
Towards this end, the local authorities proposed to develop
an All India School of Hygiene and Public Health using the
Calcutta School of Tropical Medicine and Hygiene as a
foundation. The Rockefeller Foundation provided financial aid
both for the establishment of the All India School of Hygiene
and Public Health (AHHPH), Calcutta and for public health
education in the AHHPH. The institute was established in 1932.
To serve the institute as an experimental unit in public
health practices and provide a training ground for students in
rural hygiene, the Singur Health Unit was established by an
agreement between the Government of India, the Government
of Bengal and the AHHPH. The studies were to be undertaken
in both urban and rural areas in an attempt to determine sources
of infection and relative importance of various agencies of
transmission. These studies were an expansion of the work of
the All India Institute Public Health Experiment Station, to
which the International Health Division of the Foundation gave
support from 1943 to March 1945.
Virus Research Centre, Poona
branches of health activity; and
* To attain self-sufficiency in postgraduate medical education.
In September 1956, AIIMS first opened its doors to a class
of41 men and nine women medical students. Since then, AHMs
has emerged as India’s chief center for medical education and
for training teachers of medicine.
The Foundation has been able to play a minor, though
important, role in the development of this institute. Fellowships
were awarded to three of the staff. Since 1957 six travel grants
enabled members of the faculty and administrators to visit
medical centers in the United States, Europe, and Japan. A total
of $ 300,000 were appropriated for the purchase and shipment
of teaching and research equipment. Early in I960, the Board
of Trustees designated some $ 500,000 to be used to meet the
foreign exchange requirements for the construction of the
hospital clinic complex. Further, a grant of $200,000 was made
for equipment for the institute’s clinical departments, bringing
to more than $ 1,000,000 (million) the total of Foundation aid
given since 1958.
The Virus Research Centre in Poona, now known as the
Dr. Lucien A.Gregg, the Rockefeller Foundation’s senior
National Institute of Virology, was set up in April 1952 by the
medical representative in India, was one of the advisors for
Indian Council of Medical Research, the Government of Bombay
constructing a leaching hospital to support clinical programmes
and the Rockefeller Foundation for the study of the arthropod-
of the institute in both education and research. Through most
borne virus disease of man and domestic animals in India.
of the year, two Foundation stall* members were connected
It was the over-all function of the centre to define the
with AHMs in New Delhi, one as a consultant on general
distribution of arthropod-borne virus diseases in the various
development and the other as an adviser for the teaching center
regions of India, to collect and identify new viruses, to study
in rural medicine al the community health unit in the Kurali
their natural history emphasising those agents which were
village outside New Delhi.
important for public health and to advise the government on
For the Sarojini Nagar health center in Delhi, Foundation
appropriate control measures. As part of the Foundation’s
funds and a matching amount from the stale provided the costs
programme of virus research, three Foundation staff members
of constructing and equipping, in three subcenters, rural clinics
were assigned to this research centre.
each with about four beds, a hostel for about ten interns, and
All India Institute of Medical Sciences (AIIMS)
quarters for medical and paramedical staff. The Department
The Government of India, in October 1943, appointed a
‘‘Health Survey and Development Committee” (commonly
known as the Bhore Committee) to make a survey of the
existing facilities in India pertaining to public health and
medical care, and to recommend lines of improvement and
development for the future. As per the recommendations of
the Committee the All India Institute of Medical Sciences
(AIIMS) was established with the following objectives:
* To develop a pattern of leaching in undergraduate and post
graduate medical education in all its branches so as to
of Social and Preventive Medicine, which administers the rural
medicine training plan, expected that when the students lived
in the villages the value of their experience would be greatly
increased.
Indian Cancer Research Centre, ICMR
The Rockefeller Foundation had appropriated $ 23.800 to
the Indian Cancer Research Centre, ICMR (Bombay), an
important medical research centre in India toward equipment
and operating expenses of a laboratory of studies on human
variation. This grant was available for three years.
demonstrate a high standard of medical education to all medical
colleges and other allied institutions in India;
The Indian Cancer Research Centre had included research
* lb bring together in one place educational facilities of the
in neuropathology in its programme since 1948. Because of
highest order for the training of personnel in all important
(Contd. on pg. 7)
IRCH NEWSLETTER. VOL X. NO.3. MAY-JUNE '96
2
The International Challenge of Tuberculosis
A Seminar
Sanjay Juvekar, one of the participants, reports on the above seminar organised by the
London School of Hygiene and Tropical Medicine at London from 6- 14th February 1996
As pari of its aim to encourage cultural and scientific
course of the epidemic based on past observations using
exchange between Britain and other countries the British
modelling techniques (This is necessary because the risk of
Council had sponsored a seminar ‘The International Challenge
exposure to tubercle baclli is an abstract phenomenon that
of Tuberculosis" to enable senior specialists, academicians
cannot be quantified statistically).
and professionals to learn about recent developments in the
field of tuberculosis. The seminar took a global view of
Tuberculosis Control Strategies
tuberculosis including the new challenges of the epidemic of
Achieving high patient adherence in diverse urban and rural
multidrug resistance in tuberculosis. It was well
settings, and structural and managerial characteristics of health
attended by professionals from African, Asian and European
service organisation associated with successful tuberculosis
countries. The following topics were covered in detail:
control were the main points of discussion. The consensus
* The challenge - global picture of tuberculosis
reached was that the occurrence of tuberculosis can be reduced
* TB control strategies
by reducing transmission of the disease, reducing susceptibility
* Economic and anthropological aspects of TB
to infection and disease, prevention of progression from known
* Recent advances and new technology
or presumed infection to disease and by treatment of active
HIV and
The Challenge - Global Picture of Tuberculosis
It is well known that tuberculosis leads to approximately
2.
5 million deaths every year, the majority of these being in
low income countries. It is estimated that about eight million
new cases of tuberculosis develop annually. Half or more of
the cases in high income countries occur among the elderly
while in low income countries, young adults are affected the
most. Though a rule of thumb says that only one in ten infected
individuals will usually develop tuberculosis, risk factors such
as simultaneous infection of Human Immunodeficiency Virus
(HIV) and Mycobacterium Tuberculosis is sure to distort this
rule because the lifetime risk of such a dually infected
individual exceeds even 30 per cent. Unless resourses are made
increasingly available to combat tuberculosis, it will always
remain a threat not only to low income but also to the so
called developed high income countries.
Dynamics of tuberculosis in a community can be well
understood from three componants of epidemiologic research,
cases of tuberculosis with priority given to infectious cases
and prophylactic treatment.
Another major issue discussed was the integrated approach
and multidisciplinary orientation to TB control with the need
to incorporating doctors and social scientists and the private
and voluntary sectors in management of TB; combining IheTB
programmes with the AIDS control programme etc. One cannot
deny that control programmes for any disease will benefit from
a thorough understanding of the broader social context in which
they are operating. For this the people’s perceptions of
symptoms, diagnosis and treatment of TB are to be known.
The way people interpret, classify and act upon symptoms of a
disease is culture bound and societally affected and hence the
need for an anthropological look at tuberculosis control. Some
of the clinicians also felt that there is a need to develop a
suitable model to assess the patient’s perceptions for
facilitating its use in fields other than anthropology.
Some experts pointed to the directly observed therapy or
DOTS (short course) as a need to achieve all the above. Infact,
namely :
* Identification of the risk factors for occurence of a particular
the World Health Organisation has already successfully
event;
* Descriptive epidemiology stating the magnitude of the
supervised chemotherapy to TB patients in some places to
implemented the DOTS concept in the form of intermittent
increase compliance and ensure that drugs arc consumed by
problem;
the patients. Under this practice, a patient has to consume anti
* Predictive epidemiology attempting to delineate the likely
TB drugs at least thrice a week in front of a health worker al
Sanjay Juvekar has a Master's degree in Anthropology and is a
the clinic. Practical problems in implementation of DOTS were
researcher on the Tuberculosis projects undertaken at FRCH
3
pointed out by some experts, especially, the problem of
FRCH NEWSLETTER. VOL X. NO3. MAY-JUNE 96
implementation of DOTS in the remote interior areas of
African and South East Asian countries. It was also pointed
out that as emphasis is laid on behavioural change in AIDS
control and on completion of treatment in TB control, there is
always a difficulty in combining these two programmes. But
this was counter argued by others who felt that TB too is not a
disease that can be tackled by doctors alone but had a social
dimension and hence could be well combined with the AIDS
control programme. Many of the representatives from high
income countries stressed on an international policy to allow
Some Observations and Impressions
One cannot deny that there exist vast differences between
more industrialised western countries and comparatively less
industrialised eastern countries. These differences are evident
in economic, political, educational and social development
Moreover, because of cultural differences, the whole
concept of health is different in various parts of the world thereby
influencing the health management practices in different
countries. Tuberculosis management is no exception to this.
only chest physicians to treat tuberculosis but keeping in mind
From the presentation and discussions at this seminar
the cultural and health sector diversity in different countries,
too it can be said that no single strategy to control TB can
it was universally accepted that such a policy could not be
work worldwide. For instance, some of the European
implemented everywhere.
countries are trying prophylactic treatment on the high risk
Economic and Anthropological Aspects of Tuberculosis
population but in a country like India this high risk population
itself is massive in number. Furthermore, when a country is
One important hurdle to developing a global TB
programme is politico-economic as in a majority of the
unable to treat already diagnosed cases how would it be possible
for that country to think of giving prophylactic treatment ?
countries the political will to implement the health policy
decisions is lacking. Instead, it would be easier to concentrate
on other avenues of tuberculosis control like developing user
friendly and affordable technology as far as drugs and
. diagnostic facilities are concerned. Another crucial need is to
find out a test for diagnosing whether a TB patient has been
completely cured. This will enable one to confirm and define
‘cure’ scientifically.
New York and Hongkong trials tell the success story of
DOTS. This has largely influenced the World Health
Organisations strategies resulting in implementation of DOTS
by WHO on a global arena. The question arises whether DOTS
can be successfully implemented in remote interior rural and
hilly terrain regions of India. Is it possible to give supervised
though intermittent therapy in these totally inaccessible areas ?
The answer is obviously no, especially as many such places
Recent Advances and New Technology
New molecular biology methodologies are currently being
developed for diagnostics and epidemiological studies of
are inacccasiblc particularly so during the mansoons. The castholds true for the majority of south-east Asian and African
countries as well.
tuberculosis. Most important of these are the use of
The use of second line drugs as anti-tuberculosis treatment
polymerase chain reactions (PCR) in diagnosis, rapid methods
is also not possible for all countries as firstly it is very costly
for antibiotic susceptibility testing and DNA fingerprinting for
and secondly diagnosis of these cases is not feasible. Rise in
typing of M. Tuberculosis. A need was felt for scientists,
drug resistant cases and the spurt in HIV infected tuberculosis
social scientists, clinicians and administrators to
cases has made the problem even more complex. Socio-cultural
understand each others role so as to strengthen the
factors responsible for tuberculosis control cannot be ignored
multidimensional approach to TB control. The use of
- the tubercle bacilli will make its presence felt in the patient’s
combination therapy in place of monotherapy was suggested
system, causing him/her to feel unwell; medical technology.
to curtail the emergence of drug resistance and modern
drugs and newer diagnostic measures will assist doctors to
methods of improving compliance were searched for. As far
diagnose and cure the disease; yet, will they make the patient
as drugs are concerned, it was learnt that in addition to the 1st
take medicines regularly ? Even if the patient knows that he
line drugs, many second line drugs were being tried like Rifa
has to take medicines regularly according to the doctor’s
diene. Rifa penliene. roxithromycin, amikacin etc. Yet aother
suggestions, he al limes, cannot comply due to economic and
trend in the West is that of chemoprophilaxis as preventive
social reasons. Thus, if at all there is a need for global control
therapy. It was said that if not the whole population, at least
of tuberculosis there have to be different strategies for
specific groups could be identified in low income countries
different countries while simultaneously retaining as many
for preventive therapy. Specific groups like Bidi workers,
similarities as possible. For this, more research has to be
people working in mines, stone quarries, cement factories and
undertaken in different parts of the world in order to understand
cotton mills have to be the target populations for preventive
people’s knowledge about illnesses, altitudes towards health
therapy.
and their practices for getting cured.
RCH NEWSLETTER, VOL X. NO3. MAY-JUNF. *96
O
4
Local Belief Systems and Practices
How They Affect Health Behaviour of Rural Women During Pregnancy
The information in this article has been obtained during the course of health training sessions of
village lais conducted by Seema Deodhar at Parinche, as part of the Parinche project of FRCH.
The information has been documented by Aarti Kelkar, some of it cross checked by interviewing
women from the village and by information obtained from the baseline survey.
Health and disease, though scientifically understood as
biological in nature are related to the people’s belief systems.
Thus, the health culture and behaviour of tiie people is
determined by their concepts about health, disease, their
classification of normal and abnormal and their bodily
experiences along with their social, cultural and religious
understanding of any phenomenon.
This wits made evident as we documented the various
beliefs and practices followed at the local level by the Parinche
women during and after pregnancy along with their personal
experiences. The concepts reported include the signs of
pregnancy, their methods of identifying the sex of the foetus,
the stage of its development, the correct food, behaviour etc,
during pregnancy to give birth to a normal child, various taboos
regarding pregnancy, health and so on.
Sex, Appearance and Nature of Foetus/Child
The foetus conceived on a full moon day is usually a girl
while on Amavasya a boy. A male foetus rotates on the left
side while the female foetus rotates on the right and shows
more movement than the male. A women feels more hungry in
case of a male foetus.
Regarding the appearance of the child, it is believed that if
tiie pregnant women has greater intake of either milk, water or
coconut water tiie child will be fair. If she has paan the child's
lips will be red. If she has a large quantity of coconut tiie child
will be born with lots of hair on the head. One shouldn’t open
the mouth too wide during pregnancy as tiie childs lips will
become too thick. During pregnancy one is not supposed to
sit cross legged. Rather, tiie legs should always he gathered
close so that the pressure would give tiie foetus a compact
Knowledge of Anatomy
The village women believe the uterus to be situated below
shape. If a pregnant women walks over the leg of another women
tiie child will resemble tiie latter.
the stomach inside the urinary bladder. This belief leads them
A diet of rice and fish curry will make the child fickle
io conclude that as the size of the foetus increases it puts greater
while if a pregnant women cuts vegetables during an eclipse
pressure on the bladder leading to an increase in the frequency
the child will be bad. The women also reported that after
of urination during pregnancy. This particular information has
delivery, a male foetus is washed with cold water while a female
been cross checked by interviewing oilier women from the village.
with hot water to make the latter more tolerant.
Signs of Pregnancy and Fetal Development
The popular signs of pregnancy as given by the women are:
nausea, vomiting. giddiness, loss of appetite, sleepiness, a
burning sensation in the chest, heaviness of breasts, muscle
pain in the legs. cramps in the stomach. One also develops
peculiar obsessions like eating mud, ash or tamarinds; pulling
on false moustaches (!) etc.
Desired Food Intake
During pregnancy, a woman is not allowed to eai foods
believed to generate heat in tiie body like raw papayas, bananas
etc. as they are thought to cause an abortion. A pregnant women
has to eat less as eating in excess will lead to an increase in tiie
size of tiie foetus causing difficulties during delivery. It is
believed that a pregnant women will suffer from night blindness
The women identified that conception takes place on the
if she crosses papaya seeds or egg shells on Saturdays and
4th and 5 til day of menstruation. It is also believed that the
normal vision would be restored only after delivery. The
development of the head of the foetus takes place in tiic Sth
treatment includes:
month while it can be identified as a living entity in the 7th month.
Seema Deodhar is the editor of an ANMs Newsletter Aayushi
published by FRCH and simultaneously conducts health training sessions
* Ealing bhakri (Bread made of jowar/bajara) at tiie doorstep
of some houses on Saturday
* Eating chana on tiie doorstep
of the Parinche lais. Aarti Kelkar is trained in health sciences and is
* Eating gram and jaggery boiled in a mud utensil
presently doing documentation for the Parinche project.
* Eating green leaves and carrots for 21 days
5
FRCH NEWSLETTER, VOL X. NO3. MAY-JUNE 96
11 a pregnant women has too many lamarinds, custard
To increase contractions a women is given “vermicelli"
apples, raw rice, areca, pepper ash, lea with jaggery there will
waler during her delivery. For a few days after delivery a pad
be discharge of while substance. If she eats during an eclipse
dipped in brandy and tumeric or in castor oil is applied to the
her child will be diseased and if she roasts anything on the pan
abdomen of the women which helps lo contract tissues and
the child will have inflammation on its skin.
thus arrest uterus prolapse and also prevents infections.
The general traditional diet of a pregnant women contains
The umbilical cord known as “vaar” has to be removed
a lot of coconut, jaggery, sunthavda (dry ginger), khaskhas
otherwise it is believed to travel upto the “kaliz (heart)” of the
(poppy seeds), milk and halim (cress). Also, the practice of
woman and kill her. The abdomen of the woman is pressed to
dohal jevan (a feast given in honour of a women during
remove the cord which comes out in the form of a red mass.
pregnancy) ensures that the women gets a lot of food rich in
The cord is usually cut with a blade and never thrown in the
vitamins, carbohydrates, iron etc.
open as it is believed that it might be used as a medium for
black magic or casting an evil eye thus, affecting the newborn.
During lactation, a women has to eat less, slowly and have
The umbilical cord is hence buried in the backyard
mostly liquid food otherwise it is believed that the infant will
suffer from diarrhoea. Also, stool softeners are included in
the diet so as to reduce incidence of piles which is quiet
common after delivery. Colostrum is not given to the child.
For the first two days the child is given sugar water or honey.
There is a common belief in the village that blood restored
in the uterus during pregnancy is converted into the foetus
which is thus considered impure. Hence, the mother and child
are isolated for a few days following childbirth.
The women reported that nowadays, though colostrum is not
In case of breast engorgement, rice paste is applied to the
given in the case of the first child many women give it in case
breasts which exerts pressure due to slight pulling effect on
of second due to the problem of breast engorgement. This
drying or hoi and cold water is poured alternately on the breasts
practice shows how people learn from their personal experiences.
Other Beliefs
There is a strict taboo on sex once it is known that the
woman has conceived. An interesting example could be given
facilitating dilation of the duels. Both these methods help to
assist in the free flow of milk. In fact, there are women in the
villages who provide treatment for breast engorgement.
Conclusion
here. There is a condition called vernix caseosa, where the
The question which arises here is what is the significance
foetus is covered with a while covering. Such type of babies
of documenting these beliefs and practices at the village level.
are believed lo be born due to sexual relations after conception.
The woman is strongly ridiculed in such cases.
Most of the health programmes fail to take into
consideration the cultural background of the people, leading
Pregnant women and new born babies are not allowed to
to a communication gap between the providers and the
lx weighed; also, abdomens of pregnant women cannot be
beneficiaries. Instead there are more chances of rational health
inspected as it is considered to be one of the means of casting
care practices being accepted by the people if the providers
the evil eye.
take into account the existing local beliefs and practices and
mould their treatment to the latter.
Health Care During and After Delivery
It is true that many beliefs, especially those regarding the
No pregnancy checkup is done. The first delivery is usually
influence of the evil eye and identification of sex and
done at the mother’s place. Generally, home deliveries are
appearance of the foetus, are very illogical and some practices
preferred by the women as :
like not allowing the new born child and its mother lo be
* It is not possible to reach the hospital in time due to transport
weighed, al times even hannful. These beliefs and practices
problems.
* Women prcfcre the deliveries to be done in sitting position
need to be discarded for the health of the mother and the child.
while in hospitals the supine position is maintained.
and the position during delivery have a perfectly scientific basis
But other traditional practices regarding the type of food given
The women reported that they felt comfortable among
and are in accordance with modern theories on maternity and
women they knew and the atmosphere at home was congenial.
infant care. For eg. sunthavda and khaskhas contain
*
In the hospital, they fell isolated." Also the women did not like
lactogenics, haliv and jaggery contain iron, milk and nachani
it if the deliveries were conducted by male doctors. The women
contain calcium elc. Also green vegetables and carrots given
informed that deliveries were performed by any woman or an
to cure blindness contain A Vitamins - and modern medicine
untrained dai in the village.
tells us that vitamin deficiency is one of the main causes ol
IRCH
NEWSLETTER, VOL X. NO.3. MAY-JUNE '96
6
blindness. Practices like conducting the first delivery at the
‘campaign’ mind set to guide all legitimate efforts for control
maternal home and isolating the mother and child a few days
of population, malaria or whatever rather than an integrated
following delivery give much needed rest to the pregnant
holistic view which sees and acts upon die health of die people
women. The practice of conducting delivery in the sitting
as dependent upon their role in the control and distribution of
position helps the mother and child as the gravitational force
resources. The accent is on high medical technology with
facilitates delivery while the modern practice of conducting
complete disregard for indigenous medicine and neglect of
delivery in the supine position facilitates only the conductor
the basic elements of public health - adequate nutrition, pure
of the delivery. These examples show die wisdom in following
water for drinking, safe handling of human and animal wastes.
die “integrated approach” by encouraging utilisation of the
adequate clothing etc. Further, in India the Rockefeller
positive traditional health practices along with modern health
Foundation was partial to research of hookworm and malaria
care and simultaneously discarding the harmful practices
rather than die more endemic cholera and even territorially
through health education of the community women
the support for health centres was unduly concentrated in
□
south India.
(Contd. from pg. 2)
But limited as are the Foundation’s funds, this type of
the excellent opportunities for neurological investigation
investment suggests a high return in better health over die
available at die centre, plans had been made to expand the
longer run; it responds to many urgent requests to the
neuropathology unit by adding neurophysiological and
Foundation for assistance in lifting the quality of health
biochemical studies. To help the Indian Cancer Research Centre
training, and it has usually stimulated a much stronger financial
expand its neurological research programme die Rockefeller
effort from others on behalf of the institutions concerned. The
Foundation made a grant of $88,200, for use over a three year
Foundation’s experiments in the incorporation of the elements
period, to the Indian Council of Medical Research.
of rural medicine into the traditional medical curriculum, its
work in controlling epidemics of malaria and hookworm and
Other Institutions
its financial and intellectual inputs in the establishment of
In 1956 die Rockefeller Foundation made grants totalling
nearly $1,000,000 to aid the general development of three
modern medical centers represents a tremendous investment
□
for India.
medical colleges in India, and to support teaching and research
in preventive medicine at a fourth Indian medical college. The
New FRCH Publications
four colleges - the Christian Medical Colleges in Vellore and
in Ludhiana, King George’s Medical College in Lucknow and
the Seth Gordhandas Sunderdas Medical College in Bombay-
represent private, provincial and muncipal institutions, and
geographically are located near major centres of population
in southern, northern and western India.
Conclusion
As is evident from the preceding paragraphs, the
1. Health Research Studies in India : A Review and Annotated
Bibliography
2nd ed. 1996, 185, Rs. 225
Brought out in two volumes, this book reviews a countrywide
study, undertaken at the instance of the Ministry of Health and Family
Welfare, to answer the questions often posed about healtii research
in India like who conducts it its extent and type, its relevance to
the present health problems etc.
planning and in die irritatingly superior attitude of the white
2. NGO’s in Rural Health Care
Dr. Amar Jesani., Manisha Gupte, Ravi DuggaL, 2nd rev. ed. 1996,
125, Rs. 110
This study, involving 45 important NGO’s. gives an insight into the
role and functions of the different types of NGOs in Maharashtra, whose
major focus is on the field of health. It aims at critically evaluating die
intervention of NGOs in rural health care, especially those using
man’s burden.
alternative models of primary health care.
intervention of the Rockefeller Foundation is historically very
important for development of health care services and health
policy in India, especially for rural areas.
True, the philanthropy of the Foundation had a base in tax
Also, ultimately, the Rockefeller Foundation too is a
product of the Western capitalist system responsible for
invading the world with expensive, irrelevant, and often
dangerour medical and public health systems. Along with this
system goes a medical world view which allows or facilitates
the commercially rewarding, discrete technological fix or
7
3. Women in Health Care : Auxiliary Nurse Midwives
Aditi Iyer, Amar Jesani, 1995, 157, Rs. 130
This study of Auxiliary Nurse Midwives (ANMs) was conducted
between 1990 and 1992. It considers the complex network of roles that
they play as health workers, wage earners. wives and mothers and
provides an understanding of die nature and spheres of subordination
and empowerment in their lives.
□
AWY.HE0,Inc
LBRARY "
AND
III
.ENITATION
) 7
NEWSLETTER, VOL X, NOS. MAY-JUNE '96
*ql2 HdT37 c Mat
WH. 3lifeaT
cos tdad th ale, Mt a Rcl a- aa H, tr
Hid qaadia
A HT" tI HeT ahadE aga.
qarn th ad I age farl g3 11 gH044?, $6 far a
aie g % a 3q Jeac 3 0,000 ah sAHita q? Uo WTaf4cF
tarq q fad?", 374 ^Udl a 311424cbel3 ch aa A "or
tal ch-, Jec 4.000 ah vHHT AT Uo Hq-He? 3P
aff gan l anviche U5 ak, 44 cile ch set R83 A
Heuc 9,000 a sHfic AT Uoh HHenf4c chldchaf 39eic c l
3Mdie q af M a dand sudd chiid g31T, H-TVhl cHI
wg 4 suefeqai, r ch&t ERT HsTd M RR ac
ale Mt a e, Waa fefbeHl ah an ch al- car tTe
& I af q6 -hazATe at 3491HIT, ea a anf t fer
chidche 4>ia a ? E i wafc {h? 3, mar a feg 3c
si2-Ei2 adIA 3 af EH 8, sHH HlV-HWis ac W als
^ata, daR HTH a uRas- at Mr. chviz aae a
I- He faql slid e i str A Rcl 82 &RT, Sell- 3 felt
gfarei al zudp if aga cH HTAT 1 gal k i f--f-
4,59,000 sari a de-I H, svil 83 ART ahee
,0,000
far f ayeic ahiV viid 8 i sH HcR ahi Haro chl t4q a
fatR fafbell ahi 3Heil vierdi ch
- H ?U3 a quil,
Jwcifed 3 HHcTfc s43"
ugu
3Hid H, 5H a8 g$
at,
tr at tT gfaa zHee al-f e 3Hchl
ET4 ah wi6?dT ah qvil4, afce?, ti ZIvala al
aT4 A ?ich{ foal SIIeT
i sefiferd 5101 sua) a cE AHr
ai? cqefach Arai ZRT ad Eid 1l $6 aqe H qe3 A
* EYe 8 s S-101 ?G-?tlld if Sic d aef soar SIe 8'1
al 44 cIPT AA td d wleT adIy d vild 8, W-g mat A
stc HTG-HT4, 5= gfarai at fM Mt ald
Fd ATas4c6 *IE ch- A, wford H * aga cl a fE t
HfeTl MMtM at fM M a ci?"T, zarar, a=
gfagrai, TE-zed a uRaea & fM aga c4 Er que 2
a aqi A ugs qidi t I
Rohl a3 a gaa, 3ce? R163 aa A 3R JRR?
4 chl co
af qtktt ah Ai-Ai Jdie &RT 39e aals 3 78
J4s4c dara ald as-a? 3Tdiei A & af-d Eid k, vid so
TATRA daTen AA Hrefach tT TARA AA AWA A AT
Ro lfsoe alevi A w% 906 3T0diei A 1 A gsaar, AA
3U«e chil fear
'A til soh anl d qH TH 33/ an At AA
that AA Solv ahi dal 3Uce child 8, vil so svil &1a chi
a a 9869 ch Mi 4 * HAid Mt aat k, at Hch? as
qe ddlei AA AMAH l ci A H84 M 8 | HH- A, Hasvid
aa ntM Mt, qfqerei a aataat aa, Mt a MW Mr
5q n A E eRT que A, 5 qaaTel AT aga AlM aaid 4s
HHsar 4 M Mr sqa fa JIT raah 81
ZE1 8 I sge A fATAA ART AT fuseil qfaa 39ed A MA
Al^lM adle A, Hrefac aldcbefr at W a faf4s
a HHe14 A vifee AHai ch fed; 39ge aidi
R AT fafr A ef-fafr qfaar * J H AMt I
Aldi,
&RT
faorsi af af-fazsii ah giaare 3 Hm M 3 cl?"T, MT
•
Hisehe cleoii A HH- dHqi aid diff a us e’ vildi
E, ‘I at ad nfdi chl vile4 a 3fd aara A 813
(fr-
alz HI AA ye HHET37, sad fafeHT al aW?9-
at HFH darn al wE?d ea k, $ JudR a fM
HHefac Jrdiei 3 A E4 3 ai?"T, sre tfscbe
FREE ABSTRACTING
j
The contents of this newsletter may be
!
abstracted without prior permission.
However,
we
would appreciate
acknowledgement of the source and
copies of any abstractions
aieioi at qiqaTel AT agd 3fac aqq qsd 8 I
qe. afedr, fcch a 27, Y.qH.3.a
3.cf.q«.
i ‘fc
gee a
Free & aa 4 Rs-fia arf
fhd ki 943 chHf^ fr d Hs 81ch? 3-8)9 yn4 sd, 3n7" A7ed
R7$R a au-T anaP rre andr ?nf^r ki
57. q+.
The views expressed in the articles are those of the
authors and not necessarily those of FRCII
Edited by Vaijayanti Aphale with assistance from Rajesh Ingle. Produced by the Foundation for Research in Community Health, 3&4, Trimiti B Apts.
85 Anand Park, Aundh. Pune - 7. Registered under the Bombay Public Trust Act. Printed at Omega Offset, Maratha Colony, Tilakwadi, Belgaum - 6.
The Foundation for Research in Community
Health
NEWSLETTER
July-August 1996
Vol. X, No.4
. /
1ob
■■ 1 ’
Decentralised Drug Management in African Countries
wzeen.
ASe Bamaco Initiative
A89 ),|
5/ s ,
( — P°0
)
Dr. S. N. Morankar
The structural adjustment programmes implemented
drugs were sold at very high prices relative to the people’s
during die 1970s and 1980s in the African and Caribbean
purchasing power. At the local markets, all types of drugs of
countries, though meant to bring about economic recovery in
varying degrees of quality were sold, but without any control
the long term, required drastic reductions in die social services
what-so-ever. The poorer segments of die population were
(education, health etc.) budgets during die transition period.
experiencing increasing difficulty in satisfying their basic
needs. Moreover, these out-of-pocket expenditures were not
Such reductions in health budgets had serious effects
being re-invested to improve die health system.
on the functioning of the health system, especially where drug
policy was based on die use of expensive non-essential drugs.
This led to an unfortunate situation of weakened
For eg. in 1985, for some of the countries, the drug
purchasing power due to worsening socio-economic
expenditures represented 50% of die resources allotted to
conditions on the one hand and reductions in government health
health, for all die wrong reasons. These drugs were procured
budgets for functioning costs and drugs on die other.
under their commercial names, supplies were not always well
managed and prescription practices were often anarchistic.
This unfavourable situation called for a recrientation
Therefore, in spite of such a large percentage of the budget
of primary health policies and for making die health care system
being allotted to drugs, in many countries where these drugs
more effective, less expensive and more sustainable over the
were supposed to be provided to the patients free of charge,
long term. Thus a series of policy reforms, collectively known
drugs were rarely available. The system had become
as die Bamako Initiative, were formulated in response to the
progressively more paralysed, due to die lack of drugs, material
rapid deterioration of public health systems in developing
countries during the structural adjustment
and personnel.
period.
Unable to have access to quality
medicine at an affordable price through die
health centres, the population resorted to
supplying itself through private pharmacies or
local markets. In private pharmacies, however,
Dr. S.N. Morankar has done his PHD in
Anthropology and is a researcher on the TB project
carried out by FRCH
116
in this issue
‘Bamaco Initiative ------------------I
Dr. S.N. Morankar
•Drug Policies of India and Bangladesh:
A Comparison-------------------. 4
tAitohadhtynnKiAapttrtiAarU^
The Bamako Initiative aims at ensuring
access to affordable essential health services
for the majority of the population, while
containing costs. It also aims at restoring
consumer confidence in the public health
Istemal : Bahulyata ke Madhya Ga ribi
system by improving the quality of services
(Article in Hindi )------------------6
and delegating greater decision-making
Dr. Anant Phadke
power - the financing of health care including salaries of the
will help reduce functioning costs, ensure quality of treatments,
health staff, the procurement and disbursement of drugs etc.
restore the people’s confidence in the health system and
is undertaken at the community level itself. In addition it seeks
respond to its demand for curative care.
to create better health by promoting behavioural change at the
household level.
The importance of die health problem (disease priority)
is measured by its frequency according to epidemiological data,
It has made a major contribution to health systems
development, pioneering decentralisation and active
its severity and repercussions on die people’s socio-economic
activities.
community participation. By late 1994, the initiative had been
implemented in 33 countries of which 28 were in Sub-Saharan
Feasibility of including the disease in the priority list
Africa, the others being Cambodia, Myanmar, Peru, Vietnam
is judged on die basis of the problem’s vulnerability to an
and Yemen. Preparatory action is underway in several countries
intervention (in this case decentralisation) by die community,
in Africa, South East Asia, Eastern Europe and Russia.
the financial viability of implementing the intervention and die
degree to which the community would be likely to accept the
This initiative involves four key strategic elements :
1. The revitalisation and extension of peripheral health care
intervention.
Each country following die Bamoko initiative has
delivery systems;
eslablised a central drug procuring unit where after an
2. A strong advocacy in favour of use of essential generic
international tendering procedure, the least expensive supplier
drugs in order to ensure access to quality drugs at affordable
is chosen, a supply system and drug management established,
prices;
and training carried out to assure their rational use. Care is
taken to see that these drugs are procured under their generic
3. The sharing of recurrent costs through community financing.
The aim is to improve and extend services by generating
sufficient income to cover some local operating costs such as
die essential drug supply, salaries of some support staff,
incentives for health workers and investment in community
health activities. Community financing is based on user fees,
prepayment for services, local taxes and various income
generating activities. In addition, communities can help pay
for health care costs by contributing labour or making direct
financial contribution.
names to avoid duplication of drugs purchased and also to avoid
die extra costs associated with brand names. Thus, using
essential drugs under their generic names can significantly
improve the cost-effectiveness of treatments. The working
groups (groups elected by die community to implement die
health care initiative at the community level) then establish an
essential drug list of specific number of drugs corresponding
to die treatment of the priority diseases. A limited number of
drugs are chosen, based on their cost-effectiveness and their
response to priority needs as well as perceived needs. And
4. Community control which involves community
quantities are ordered calculating die requirement using
responsibility for the management of local health services.
epidemiological data on drug consumption on die basis of one
Funds generated by community financing do not revert to the
illness episode per person per year.
central treasury or health ministry but remain in the community
and are controlled by it through a locally elected health
In the*community health budget, which is created in
committee. This is seen as a manifestation of a community’s
order of-priority of items and services essential in health care,
full partnership in die decision-making process and as a way
drugs and information tools feature first on die list. In fact
of ensuring that the poor become better organised and more
around 75% of the budget is appropriated by drugs alone. A
vocal in demanding health services.
proportion of revenue corresponding to the value of drugs
and information tools consumed, is blocked in a bank
In this part of die article we shall concentrate on the
account and constitutes a reserve fund, for as long as
drug procurement and supply management practices evolved
UNICEF continues to support these drug and information
and practised as part of the initiative.
tool costs. For eg. in Benin, three prepacked kits, every
containing 40 essential drugs, are provided to each
Logistical Support : Drug Supply and Distribution
community health centre by the UNICEF, each kit having a
purchase value of US $ 1200. The revenue realised from
Regarding drugs the Bamako Initiative aims at ensuring
a regular supply of essential drugs to the health centres which
2
the sale of these kits is then put in a bank which constitutes
the reserve fund.
FRCH NEWSLETTER, VOL X. NO.4, JULY-AUG. *96
Drug Donations
protection from the environment like a waterproof roof, a
location protected against floods, sufficient ventilation etc.
Four types of drug donations exist and distributions are
made according to their usage :
and measures against thefts like burglar bars in the windows,
solid doors with two locks, one for the president of the
1. Drugs received as emergency assistance in the case of
natural disasters - they are not sold.
managing committee and other for the health centre nurse.
When the stocks arrive the drugs are handed over to the
2. Drugs in the national essential drug list that are received as
president of the management committee and the nurse in charge
a gift or a special short or long term assistance - they are
of the centre. Together, they make a complete inventory and
registered on the stock forms and sold. In addition to
register the drug quantities on the stock forms. The drugs arc
facilitating programme management in the start-up phase, the
stocked in the secure rooms prepared for this purpose by the
sale of these donated drugs generally generates sufficient
community. These drugs constitute the main stock.
revenue to create a reserve fund and to finance certain local
Periodically, generally monthly, the president of the committee
and the nurse in charge of the health centre take small stocks
functioning costs.
kept in a closed cupboard in the treatment room which are
3. Drugs not included in the national essential drug list - the
available for daily use.
director of pharmacies must make a decision concerning their
utilisation in line with the final procedures.
4.
Monthly Supervision
Drugs used for special programmes (tuberculosis and
the central purchasing unit
Based on three randomly selected drugs, the supervisor
negotiates with the supplying organisation on how to proceed.
totals the quantity of each drug prescribed according to the
leprosy, contraceptives etc.) -
drugs and revenue register. He then checks whether the
Drug Prescription
theoretical stock of these three drugs in the main stock
according to the stock forms, corresponds to the quantity found
Flow charts are used by the health workers, which are
during the supervisor’s inventory. Finally, using the same
decision trees to decide upon which therapy to apply or whether
method, he calculates theoretical quantity for the ‘daily use’
to refer a patient. Decision trees standardise guidelines to
assure quality care and avoid inappropriate and potentially
stock from the drugs and revenue register and compares it
to an inventory he takes of this ‘daily use’ stock in the health
dangerous treatments. For the health system as a whole, flow
centre. If these checks reveal an important difference, the
charts help reduce costs by limiting over-prescription and
medical officer will carry out a complete inventory of
facilitate the management of drugs and equipment They provide
these stocks.
nurses with concrete guidelines and for the health systems,
they ensure optimal use of available resources.
Monthly Supervision of Flow-chart Use
National and provincial directorates are provided pick
Two methods of supervision are used : direct and
up vans to be used for : delivery of material, cold-chain,
indirect. The direct method is based on observations of the.
injection and sterilisation material, pre-packed kits of essential
health staff at work. This method focuses on history taking,
drugs, forms, files, registers, vaccines, etc.
choice of flow chart, decisions taken, drugs prescribed and
their quantities, and the advise given.
Drug Management and Supervision
The indirect method is based on the analysis of the
The presence of drugs and money in the health centres
registers to verify whether reasons for consultations are
necessitates rigorous management and control, exercised by
registered in the form of complaints, whether the drugs and
the users, the community, and the health system supervisors.
dosages recorded are in line with the flow charts, and whether
Such careful management is applied to both the daily health
referrals to higher levels were justified. Supervisors from the
care activities and the administrative task in the health centre.
district, provincial and national level verify drug management
and storage conditions during their routine visits and during
The community is required to ensure a minimum
the semestrial monitoring sessions.
number of storage safety measures before availing of the
donation of essential drugs. These include measures for
3
(To be continued in the next issue)
□
FRCH NEWSLETTER VOLX NO 4 RUY-AUG
96
Drug Policies of India and Bangladesh :
A Comparison
A rational drug policy addresses the issue of prevention
what will prevent a major share of production from being
of, withdraw of and protection against irrational and hazardous
diverted to non-essential areas? In fact MNCs are worst
drugs and simultaneously, provision for easy availability of
offenders when it comes to production of irrational and
essential and life-saving drugs. Frequently, the blame for India’s
hazardous drugs and non-production of essential drugs - die small
inability to address these issues in health care management is
scale sector produces more bulk drugs than MNCs.
laid by policy makers and implementers on India’s third world
status. The most effective way of countering this argument
Essential Drug List
would be to compare India’s drug policy to that of Bangladesh
Bangladesh .• * A basic essential drug list of 150 drugs
- a poorer and less powerful cousin within the subcontinent.
established with 100 specialised drugs in the supplementary list
* 150 drugs for tertiary care
Essence of Drug Policy
* 45 drugs for primary care
Bangladesh : The 1982 National Drug Policy of Bangladesh
* 12 drugs for village health workers
was seen as an integral part of die National Health Policy -
applicable for the modern as well as the traditional sector and
for the public as well as die private sector. The objective of
the National Drug Policy was to rationalise procurement,
production, quality control, distribution and drug pricing and
bring it under a single legislative and administrative control.
India : Does the proposed New Drug Policy procure larger
India: No national essen tial drug list. Attemp
have been made
by states eg. Delhi State, Tamil Nadu to formulate essential
drug list, but these are only for the public sector health
institutions. Since 80% of the drug usage is in the private sector,
the formulation and implementation of an essential drug list
concept, unless it is for the private as well as public sector, has
limited usage.
profits for the industry or is there really a good deal in the
To make matters worse, unlike in the earlier policies,
offing for the common man? While the drug policy of
essentiality of drugs as a criteria for price control is proposed to
Bangladesh is directly consumer friendly the Indian drug policy
be completely done away with in the ensuing drug policy.
will bene it the common man only if greater concessions to
the pharmaceutical industry can promote larger domestic
National Drug Formulary
production and thereby increase availability and reduce costs
Bangladesh : Preparation and publication of a National Drug
in the long run.
Formulary
India : Last national drug formulary was prepared in 1979.
Hazardous/Irrational Drugs
Bangladesh : Sixteen Criteria were evolved to categorise
Neither the 1986 nor the 1994 New Drug Policies ensured its
revision. .
irrational and hazardous drugs to be withdrawn from the market
The drugs to be banned were divided into three categories
Use of Generic Names
according to their harmfulness and impotency namely schedule
Bangladesh : Compulsory printing of generic names with or
one, two and three respectively. Accordingly, the drug control
without brand names for 45 primary care drugs.
ordinance was implemented on 12th June 1982, effectively
putting into law the Expert Committee’s recommendations,
India: No such provision.
although prolonging the time allowed for implementation of
Price Control
the three schedules to six, nine and eighteen months
Bangladesh : Prices reduced by increasing local production
respectively. Also, there is prescription control of toxic
of drugs and by other practices like not condsidering luxury
poisonous and habit forming drugs.
packaging charges while fixing prices etc. Also there is a
India: In our country loopholes between jurisdiction and lack
control of labeling and advertising which along with reducing
of accountability in drug policy matters between centre, state,
confusion of the consumers also helps to reduce prices.
Chemicals Ministry, Health Ministry and Commerce Ministry
India: Steep increase in prices expected if New Drug Policy
have never allowed rationalisation of drug policy and seen
is implemented under which any drug whose national turnover
repeated attempts sabotaged. In die absense of a clear cut policy
is not more than Rs. 4 crore, would be free from price
to ensure and channelise drug production in a certain direction,
control.Thus only 50% of drugs will come under price control
4
FRCH NEWSLETTER. VOL X. NO.4. JULY-AUG. 96
as compared to previous 70%. A decision is expected to be
Alternative Medicine
made to allow 100% MAPE (Maximum allowable
Bangladesh: Revised 1940 Drugs Act to include a registration
manufacturing expenses) on even the 73 drugs coming under
system for Ayurvedic, Unani and Homeopathic medecines.
price control. This and the introduction of the GATT patent
India: Proposal to set up a separate department for Ayurvedic,
regime in the coming years is expected to lead to further
Unani, Homeopathic and Siddi systems of medicine under the
widespread increase in prices as the US experience tells us
New Drug Policy.
that competition does not work in the market for drugs and
prices keep on spiralling.
Ceiling prices are purported to be fixed for the
commonly marketed standard pack-sizes of price-controlled
formulations and even small scale units will have to follow the
stipulated prices.
Generic drugs are also to come under the discipline of
controlled pricing system.
Tax and duty concessions are expected to encourage
research and development Indigenously developed drugs will
not be subject to price control.
Multinationals
Bangladesh: Regulation of technology transfer and licensing
agreements with foreign collaborators.
TNC’s prevented from manufacturing simple products
like common analgesics, vitamins, antiacids.
Drug Legislation
Bangladesh : Establishment of special drug courts and heavy
penalties.
Introduction of medical audit and registration of all
heal Ui workers
Abolition of Private Practice for all teachers in
government medical colleges and post graduate institutes and
doctors upto the level of junior consultants.
Introduction of various other legislative and
administrative measure.
India : In India it is the constitutional duty of the State to
Raise the Level of Nutrition and the Standard of Living and to
Improve Public Health. The state shall regard the raising of
the level of nutrition and the improvement of public health as
among its primary duties amd in particular, the slate shall
endeavour to bring about prohibition of the consumption except
India: Hathi Commitee report of 1975 had detailed the sins
for medical purposes of intoxicating drinks and of drugs which
of the foreign sector in the drug industry. Yet in die ensuing
are injurious to health.
drug policy the government is expected to allow foreign equity
The drugs and cosmetics act, 1940 and 1982, are the
up to 51% for all bulk drugs, their intermediaries and
main drug legislations that are supposed to provide some form
formulations.
of control over the manufacture and sale of drugs. Under these
Number of items reserved for the public sector
legislations the Drug Controller of India has the powers to
undertakings to be reduced according to whether die capacity
prohibit manufacture of drugs which are not in public interest.
is adequate to meet the country’s demand.
Also the Central Government has the power to prohibit
Product patents are to be eliminated and use of process
patents to be limited.
Good Manufacturing Practices
Bangladesh : Enforcement of good manufacturing practices
and adequate quality control - greater vigilance and easier
testing procedures.
Establishment of registered retail pharmacies, under
the supervision of qualified pharmacists, at every government
hospital. Restriction of ownership of retail pharmacies to
professional pharmacists only.
Drug Administration strenthened by training all thana
health administrators to act as drug inspectors.
manufacture, sale etc. of drugs and cosmetics in public interest
- without prejudice to any other provision contained in this
chapter if the central government is satisfied, that the use of
any drugs or cosmetics is likely to involve any risk to human
beings or animals, or that any drugs does not have the
therapeutic value claimed, or purported to be claimed for it of
contained ingredients and in such quantity for which there is
no therapeutic justification and that in the public interest it is
necessary or expedient so to do then the government may, by
notification in the official gazette prohibit the manufacture,
sale and distribution of such drugs or cosmetic. Whoever
himself or by any other person on his behalf manufactures or
sells or distributes any drug or cosmetics in contravention of
India: Proposal to set up a National Drug Control Lab and a
the provisions of any notification issued under section 26A,
National Drug Authority (ND A) which is expected to eliminate
shall be punishable for a prison sentence and/or a fine.
industry’s difficulty in dealing with different government
departments like health and chemicals, and reinforce the
In a landmark judgement, the. Consumer Protection Act
has been widened to cover health services.
inspectorate system to monitor the quality of drugs in the
market.
5
(Contd. on pg. 8)
FRCH NEWSLETTER VOL X NO 4 IIILY-ALIG
96
3iiufaa a 31Uf 3 3441 seHiel:
digedI ch 49
ST. 31--d thec
HRd 4 Jeac ad «T‘T 7.000 chiis qqar th Heq cht .
te nte BTedleif 3 sid ache m -189 Ha a 35 Twildid
ca seHle Eht t, sor * aql at age ast chat «‘TIR at
adi i c& a Rite ardle A sH9T: 129 At 151 qvildfiq
g t, sasiuche Hdvfch 8 4 I qe * HIT nMT t fo StHle a
aar, agd t Ha MT Wiei a 31Tgf a T l
3 ze aqrei h
aga a feefll t Eorei ch i w afadchyuf
Hf22pur a t a sor-ich seHle * "ei &‘ t ter 11 q w
cej aft, quanefige ZRT HERI 25 UCh sfleie fore h, aerei ct
anqf si stmle a zu eg shd T2 3144 ZRT * yf a
Ts 11
3yecdT a Razd
sW{ set A AM>i, Uoh ad a &RH 3uce chils A
aori A^r ten him *rema? i mmtA A te-tete
c ten H 3704- MRHT A af 349465 11 MW MTMT TAT ft 3-
sachif a HTHTf1cH-3nf4ch qechi ah
THR HId gy
Nt uigeeft N, 149 ga * d ahee 14 f nd H a (9.4%), A A a
(frueans aHdt), qaT3 a anlys a ETcwif-ich tl gfaaren
end d affach f- H Jue 9 | At teN arelle H. 158 qa H
a ale-zh sa-" H zf c sufef ch aas ch fer, HIRT
d Amr 46 H3 (39%) it, A 2 end d afach fe- n aue m i
ek: uigaef a teH JTHdlei N, 5- afad mhtA A A Uo
a algei A fachfen, ad A? 4 W aa h sep-svidt ftnr
TaTI
aga HR m>A «‘IidR nA Zed w1
MW ti t ft HIRT fie N HTdwifch ta gfaar
3 te mmtA a enyf, fuft Ar A mhtA A angs mt At
qarai a He algin
Hf ^AnmiiAn^AAT mfAt &elei i &THe !
310444 3 44H H’ chl 3028 MT, Hidwisich OTR RA
ala H aqle ah allys c t46u 9 a-ich $e Hed da Hdwis-ich •
Ar h aql3 a chu ah saqy N 3724- chi-l
Jeac aa H di- u Ud ft, Uo a11o 3dief, Uch
g&k 30dlie a Uoh sei Ri Rd Bdid (He Nt) chi afaffac
a43 a 5u H qll HMT l sH 33 H MM
Sozd A aqrei A A «dR te mtA tet ti
anfaat al stnid
374- cl fadiq q{UT, HldI sie H anqfaqi MT stHke
ah Rte qeco MT Ate MT I
uhd ch as sie ah k
sh 3844- 4 35 qeci c fd sharfaf, fazis skqq ah
ac agio at sl4, a 5 tit) 65 q HR ch adT3 (He’lT,
aa Ar A A1 5 skqa At 3-13 aHHR qteA mt
m frac n &cbich?" aldshH ah al- a ald Am ch
RmH H NtR tel HMT W 1
wlscz) a He chl U deid t 1 qu 1991-92 N Hidws-ich aa H
the angf 5. 56.22,862.80 3id eT‘ 56 cl’ qqar chi a;
safch ad 1991-92 N, fo Ar a RA EHR qIe =dH 3 HI
21.28 alls quaf a E - (af cast 87
I
angin a ns q413 a JoR
gea al affde
3044-1 ch Uoh feed 3 tq n, Hldvsc At RA Ar th
sie mt gi A, 3nic ski sric aqie A qrbell A alichi At
i-e{t, afaacyof, td?-lic aqrei At tente S-cQT-i 2
seHig MT JR A ae eg faxeiqu soha HMTI
Nt uuee H d Heuch ch ad- 42 Hvildiq qaT37 (26-50
JohR A), 171 H MT Ure si effa qqral, W, fey,
3=9 a, Rte Tlehi &6qH, anuf a Ts i such HHge
egi MT 3H
qeqyai At sie? A fTe 3 rr At tiqe H[HIfs1ch-znfac
M>rA ah ate if tra- rfaa MrN MTT gai ftMT HMT I"
qRH: McHMTMMTRAwiMeANfaQtWAsM^
cicc fofedi At tonite Ar 3 Won efq chidchef 8 aa 4
mt adys fadcnyuf tA ch sJle 44 mt At afadchyof tA
q.R.f.ua. &RT denfeid aWi 324= a qe a-d d l
a 340 afach mt At ^mAhM) ald as cut ns fo fadchy"i
FRCH NEWSLETTER, VOL X, NO.4^JULY-AUG.' 96
6
qpa ah 34 a afd
e andd 3ich, si? ah Afeich
feidd 41
qnqdl3 2 Hq aed E l
toto ft qeri ast ch— angf 3 aR" serfehef afachlf?«i
=f WoR 3 sie? 3 qeaf a Uo aga as 349ld 14
qts cfil a sHs afacchyof *Rvi8t/ te-lch aqi a *Rwie{
se9H ar di- H afch can ford Ts ar l
a alez al d aar tles 2h Jd sft
to aa ElT
a i tofe, fefebcem totot ftft to fer- t to ftton 551
eefeC a anfc * i zud
to ‘aTe‘ at adi 35
d
‘HScquuf’ zifaf, anfe 3 to it ferdd d i
fv a a qe at J0en, tldwif-1c aa 25 Te ofach
ste a acet g{ to a as a, toft as 3 ZT3,
faacyof Ei Eleifo, Hldwfc ala ft afaccyuf SMeR chl
zftraf a 344 to ton to a94 qie qAI ? 4 RRe-de
3Hld svi al al 3021 $u afch HT TH 1
a aur tlvid a, quc aue d * 1ed tort a allchi ft aeeld
J fld- $ adsl al JHldd cin al ae4
ana l fr-of 3-er-i to eqi chi he ton 4 69 " 41,
sH a-2ut 3P74 H E4 fadehyof fafoetiid vitrdi chl
blsct $e "H cizchi chi 31244- schaT, vi HldRT svid H Sl’T
ZRT for to ald
8 3 adeR a mfad ad t, N, sie?
c f- fasbei fre (frs) cFT t, qqri a chmfai cht
fy"- fifaf, siezi 3 qe ufreqaf cRT t46q a HR, qqri ah
3fuch toft aqrei ft) qe fri, tom so torn al qe aR"IT,
fe ga freft tom toft eht, tot it tom wHTt, a tigz
ton o to, anfe tot tot it fifaf t toft fe torn a 393
it WIH q-I"
vi Hoh l
digee a tot a HH- adli ft> ton * s
3Hci@dT, HAvi a HTH11c-3nf4ch faf, scaife 1
se araa- t qe si ae ahl H1 ftt ton nser“t
uR"IH : ae ald a 24 a t fe toft 8 ft ftt UH ( «TT
qe ftt at to, ftton ft; to tor qarai a HTHI-4 5u t torn
qfdaT eftbid Si? a 5ol W to? t a ae au T soh
chi t, to; ton ft 3-4h sI- ahl a t t a sh WCR
ahdm 12.6 afAl STc23i * et, cals chmf4 ERI jmrtosnnftm
6u d 3 tot srt qqri ft> ptoM a aa- ae chl Hare ton
ufacT3T ch H4-H4, sasctil H Hlasad sohet 3-4 qfchl ch d
Ta i sra-
chH fem i
3-c ART sHle a vII aleft aqiei, faztuch 3 adl3l ft;
SiZZi 2 fed, adl chiqfar &RT b Ts vil-ciRgi,
(to, dubeiz s anafc qfcbrsi) ah HH d ton Ta JR
3 qais chuuf-qi ch uff-if et, ‘R- fafoety fre’ 3 Had
HEcqquf ald t l Eleifo
shifed Hlf
W cRI mfer, JeR to alel a
a aldt tot cpl,
stHie ft> &RI ei vIA alei Hqa-4 ft> saqa H s{R saschedld
fTel (das) to 384 a 31q94cal 11
gol-i W (snei) qqlei a aaq fas
3 afr 4 qerrqof tor i, fe? i se
“IRT 4, U sfuft fashel SRI qeh to ft, chee Jes ft)
/ 68.1 ufl H afch fv aa a 50 ufk d sfc Hdwif-ic
&TaR W toft to to eqrai nit, tor to ah era ad sA (a
to 3 sieR &RT fzre 3 ald ch tu 4 HI- & wd % i
it fr) ft; allchi 37R HIa ft; 31a- d sild fan so tot smR a
adi, tor toft to 3, to6t ft; to aura nt i s
qqri 3 Heat 3 * ge ah t6u CRT HBcquof 5q #
gafar ton i aqri ch aed gy eur
chiUT, sie &RT adI
«,
Uch to ft, al it A toft 5. 497.99 ast at, si fo eqri a ce
toft, 5. 4.436/- ch 11.23 gfaie aft 1
24 ahl alichl * aed 1a 11 Eleisch Uch Hen ad al Te 4
ser-IT, Sier al tor R cod 6, fe? ftt to qra TT fob
st27 sHd fed Hqa- to > to Je
afad Je ft> a10 enfc arqeqy
fereft Ts aal a ahl
$6 aa- &RT, Hldwfc a toft al ft, sTed SRI
He zfat a anfac awn c *? it ?, aifh arfuch Heu
at zam ferA U mad ?fgi c HIHA Hfche to e
afadcyof adrei ft; sene ft to ae 31qczq ah i
«T‘Ia nm 146 tor TAT fe $ affeachyut tot a cr("T, aqrsi
Hohrft ? i
3 to gy to af auie d sie ch m3 set
aar 23 a HT4-m s-f to * d ft
tot a i
qefed as sia? to chH aaI ad ft to to ft affech qar
W scd “H ald ud ch 63.6 Hf te eyd ft fem vilel k. svi
to ft
8lqule (55.4 NfeATet) ft cto ^to; 11 HR ft ^wn
NCHA
A 2 lav
7
- C.
/ r ‘ V owe" FRCH NEWSIETTER, VOL X, NO.4JULY-AUG: 96
a ax oh 30d JHHI a 3TR R3, HHe1d 4 on? HidIT sid
fear w ar, af dieef 5. 37,134/- a at 1 ad: af digar 5.
a trige b a z faH (3i t ST) at 1991-92 a sufef
30,280/- a cht at, w fe ad 1991-92 4 afa uryeeft, 5. 3,63,000
a JHR. ae 319c4, svit a Hldsc ala H afd Rh, afd JET,
ch afsc alddf td al 8.34 afar s i era: afa diuee 2 ena?S
:49I: s. 4.76 4 5. 2.08
arffe de ch uiuue 4 aqrn a 3nyf agr
I
(199l)
17.70 ART5 “b EKT E
c^f^T J-Hf- fell 3JFT ar
fed ahed 8.34
afRid aar Rar vid 3 af qqra a HH angf m saachy
da a stHle fear wIq, at digae - andist a an aid m
md-f tr ufaaren H ale a qq137 3 Ja al aluld
difa cl 5did qaf da d fear dr tche s i
s ?t, Sell- aserd Hdwfc tle gfaari (Grets)
al 34414 cid t, 3- 394 dH4 th Selv eg 311424c q*t
aar urag d H fe aifed I wg ae Uo a fzriad t
HRT sie 4 He aarerf a =H ags, Mt 3
3R 384- $ &RIH 8H- IT au so uiu4Ut 4 Sd{ <fa ci, 8
Hdwfc da a w 5. 21.28 mt? a 5. 0.56 mt? a at 1
aqT3I a ‘aie? s co, 3-6 dMyR a tle- ah aed s i EHI, W
as eTs HdRT sie a aqri a qrof 311424chd an T chi
AT ah que *, ?41 &RT so wil- ald dd ah 4 3-HI- «‘TPT I
ch fold qafd d 1 3fac % 1 3: any HdRT sie chi c413 chi
WR"IH : HdRT sie a, 1993 4 vils H, Uo f- H,
md-f, tr gfaarai 3 afasha 6q d gh T 145 am z
faHn (3n9isT) H 3/4 zifqi 4 fed, gh am chi cqIT th, qi
elldyachey, aaraaf a mft ? qff, afeo affaccnyuf Maid d
34 314c4 3 ci?" q& q8 st qid s l
□
(f-e 3748 : 4)ai afaeda)
a tr cct 3 82 to af ? re i (as ald a- 23 an ? fe
53 145 ?ifi E 4, agd a afgr ah ahis 1 am chi cdri ahl
(Contd. from pg. 5)
Conclusion
8dT qe Rar aar ar) i
bl2 a as 9mr H at, dyeic aql3 4 He 4 319id a,
in the above comparisions the drug policy of Bangladesh
zifai ERT am a w?e aarafi a He, I- d 221.5 afl 3
comes across as a bold initiative taken to make the policy more
aid ar, 3d 5. 7.97 chi ar, w fe q*f ch- (A3 a HAj") ah
sod ana s-6 3/csi a chei afac ar 1
pharmaceutical MNCs. India, which is blindly opening its
economy to all multinationals should take some lessons from
3: tun hi fed H, at Uy U$ a, ae? ah aqT3 ch ge
al $el JqVld aga 3fc a -8 W-d ailhi s l afr &RT
tle art alei adI cl adaM end 15 sfld &, at fe 3fac
at qe W-g aqie-iq i ai
consumer friendly even at the cost of the profits of
A- star aifed l
Bangladesh and resist any attempts to be coerced into sacrificing
the interests of its own citizens. The policy should be formulated
only after discussions at various levels with professional bodies.
health groups, rational drug groups, consumer groups and
voluntary and people's organisations so that any unhealthy
imbalance profiting only a certain section of the people is avoided.
3098
Compiled from the HHMR press clippings and the
srsch tra a- 2 am ?M faH (nuret-andist)
a *0 3 424 cl 344- chMi a qql3N a ad 31ld24chdl
a at Uy Al c adll c quie chi, ?a JR ar 3HI-
publication ’Banned and Bannable Drugs' published by
Voluntary Health Association of India.
□
fe
at aa dl-3 at ot a 34 did Heach ? al qaf a faacyuf
nq d Sellv E i
URVIH : 344- 2 3-f a— aid 86 digael 3
andist a R a audRg/Teo 3 aaR R atRd a fer
aqle a alq9cbel, ad- af * Ue A 5. 67418/- s af
? 5. 11.68 a at ($H5 &t.4. a $8 ?M ah ?n Ifc qe
€) 1 5 8E uuda al 3UdR4 3R c&I 3 STAR ar ate 3
sod adri ahl 3lyi, sid fe ^a 344- th as?r an a st ara
FREE ABSTRACTING
The contents of this newsletter may be
abstracted without prior permission.
However, we
would
appreciate
acknowledgement of the source and
copies of any abstractions
The views expressed in the articles are those of the
authors and not necessarily those of FRCH
Edited by Vaijayanti Aphale with assistance from Rajesh Ingle. Produced by the Foundation for Research in Community Health, 3 &4, Trimiti B Apts,
85 Anand Park, Aundh, Pune - 7. Registered under the Bombay Public Trust Act. Printed at Omega Offset, Maratha Colony, Tilakwadi. Belgaum - 6.
The F oundation for Research in Community H ealth
Vol. X, No.5
Sept.- Oct. 1996
Decentralised Health Care Management in African Countries
Bamako Initiative
o r LIBRARY
‘ (
AND
A
DOCUMENTATION
UNIT
Dr. S. N. Morankar
In the first part of this article published in the
July-Aug.*96 issue of FRCH Newsletter,
SANGALOR%
Because the revenue is directly proportional to drug
the drug
costs, such a system reduces the risk of bankruptcy; with
procurement and supply management practices under the
a fixed consultation payment or pre-payment, over-
Bamako Initiative were highlighted. This concluding part
prescription can lead to financial problems. Cost variability
discusses the community financing and management
at the health centre level is mainly due to variability in the
practices evolved therein.
quantities of drugs used.
Along with access to quality drugs and health care
In contrast to a pre-payment system, the pricing system
delivery systems, the key strategic elements of the Bamako
used in Benin and Guinea has the advantage that revenue
Initiative are community financing, supervision and training,
increases as health service utilisation increases though, if
and management and information systems.
utilization is low, there is a risk that the fixed operating costs
might not be recovered. Since the price covers the complete
Community Financing
treatment it encourages patients to finish their treatment, in
Three basic alternatives exist for community
contrast to a system where they pay for each drug.
financing : 1) A fixed consultation price (regardless of the
Ethically however, this system, like payment of drugs
type of treatment); 2) Direct payment for drugs (at prices
proportional to their real costs); and 3) Pre-payment
schemes where periodic contributions are made,
independent of whether one uses the health services or not.
or a fixed consultation price, places the financial burden on
the sick. Moreover, unlike the fixed consultation price, this
system could cause difficulties in payment for patients
suffering from severe illnesses requiring expensive
Both Benin and Guinea have chosen a community
financing system which combines the first and second
treatments. To redress this anomaly a system of internal
subsidies has been instituted.
alternative - a price paid for the complete treatment. This
The pricing system in Benin involves the
price is set as a function of the actual costs
of drugs provided for treatment. However in
certain vital treatments, prices are standardised.
Every
health
problem
has
a
single
corresponding price, even if several alternative
treatments exist.__________________________
Dr. S.N. Morankar has done his PhD in
Anthropology and is a researcher on the TB project
carried out by FRCH
in this Issue
identification of those costs that have to be
♦ Bamako Initiative -.-------------............1
Dr. S.N. Morankar
recovered from community financing system
♦ Parinche Project in the Light of
Bamako Initiative-----.---.-.....-.4Dr. R.V. Banpel
total fixed costs, c) village health workers’
♦ Hospital Waste Management.--.--...... 6
Shrinjwas Indapurkar
Assuming an effective payment rate of 75%
♦Sarvajanik Kshetra
(Article in Hindi-------------8
Dr. N.H. Antia
revenue namely, a) essential drug costs, b)
remuneration and, d) personnel incentives.
of expected or theoretical revenue, the
treatment price should be about three times
the drug costs of that treatment.
To mitigate the inequity caused by putting the burden
of payment on the sick, the pricing system has been adjusted
in accordance with the seriousness of the illness. Chronic
members is provided by the facilitators. District medical
officers and staff from other related sectors are appointed
as facilitators for the management committees' training.
Supervision :
diseases with prolonged treatment, such as tuberculosis,
Supervision, a very important aspect of the programme,
leprosy etc. are treated free of charge as these programmes
aims to change health staff behaviour, to ensure good service
are assisted by external aid organisations. Moreover, revenue
quality, and to reinforce training. The programmes adopt
generated from curative care finances the cost of preventive
systems of formative supervision which focus on improving
activities.
health skills, instead of negative sanctions.
Budgeting :
Supervision teams spend one day in each health centre,
In Benin each health centre has created a managing
where they examine the quality of curative care (checking
committee consisting of community representatives and
the extent to which the flow charts are being followed), the
health staff. The committee prepares budgets at the end of
quality of MCH activities, and the soundness of the drug
the financial year of the total revenue collected in that year
& financial management. The supervision is carried out
minus the authorised expenditures to cover petty operating costs.
through direct observation of health staff at work, and by
record analysis. The supervisors try to avoid any direct
Benin has created seven main budget items to be
allocated resources in order of priority : a) Drugs and
information tools, b) Petrol for the cold-chain and
sterilization, c) Petrol for the vehicles, d) Office supplies,
e) Incentive payment for health staff, f) Repairs of vehicles
and refrigerators, and g) Other investments.
intervention in the activities of the health staff; they are
present during the consultations without influencing the health 1
worker, and only intervene when asked by the health worker
or when their silence would permit harm to be done to a
patient. The supervisor then gives his assessment of the
activities he observed. He congratulates the health staff for
Once these mandatory items have been included in
positive results and opens up a dialogue on corrective action.
the budget, the management committee and the health centre
The supervisor/medical officer also carries out monthly
staff can decide how to use the remaining funds. A proportion
supervision of prices and treatments and of drug prescriptions
of revenue, corresponding to the value of drugs and
by random checks of relevant files. Monthly supervision of
information tools consumed, is blocked in a bank account
financial management too is monitored similarly.
and constitutes a reserve fund, for as long as UNICEF
continues to support these drug and information tool costs.
Training and Supervision
As a result of this approach a team spirit has developed
between supervisors and health staff. In fact the health staff
have often requested more frequent supervision visits. Also,
health staff skills have improved and a number of weaknesses
Training :
* Technical Training : A single technical training session
focused on three key areas : EPI techniques, cold chain
maintenance and management, and flow charts. In flow chart
in the system have been identified. Supervision appears to
have contributed to sensitizing health staff about the problems
stemming from indiscriminate over prescription : although (
it could increase revenue, it jeopardizes the quality of care.
training, the nurses themselves developed their own flow
charts, supervised by physicians and assisted by clinical
specialists.
* Training of management committees : Resolving the health
problems in the community requires that the various parties
in the committee have skills in several domains : drug
management, management of financial resources, supervision,
monitoring of coverage, social mobilization etc.
Management and Information System
The Bamako initiative has contributed significantly to
developing managerial and organizational skills at all levels.
Bi-annual health centre monitoring and micro-planning
systems, in place in Benin, Cameroon, Guinea, Glainea-
Bissau, Mali, Nigeria and Senegal, enable health centres to
monitor coverage, identify problems and determine solutions
Management Committees consist of three to five
twice yearly. District health staff and communities, through
members including the physician or nurse in charge of the
their health committees, are involved in the process. In Kenya,
health centre and at least two representatives selected by
a community-based monitoring system, known as the “Chalk
the community itself. Committee members participate in
and Board” system, is managed by community health workers
programme management, especially in the monitoring and
who collect data, compile it and record it each month on
supervision, during which ongoing training for committee
a chalkboard displayed at the community pharmacy. The
FRCH NEWSLETTER, VOL X, NO.5, SEPT.-OCT. '96
2
information is discussed by the community and serves as
the basis for planning health activities.
1991 revealed the following areas in need of attention :
* While the Bamako Initiative has made progress in ensuring
Any information registered at a given level of the
the availability of low-cost drugs, many other determinants
system has to be used directly at that level by health.staff
of the quality of care like correct case management,
responsible for its collation. Only information essential for
communication between patients and health workers and
one of the following purposes is retained : a) The provision
attendence of health workers have yet to improve.
of direct health services (e.g. MCH, treatment); b) Local
*
management of resources and activities (e.g. drugs & financial
train providers in appropriate prescription practices to ensure
management scheduling of outreach sessions);c) Supervision
that they respond to their training rather than to other
of quality of care and management; d) Monitoring of coverage,
incentives, including financial ones, that may encourage over-
drug use and cost recovery. This way the information recorded
prescriplion or the inappropriate use of drugs.
is minimised and repetitions are avoided.
* So far, most efforts have been directed towards community
In the area of drug use, better ways must be found to
involvement in the financing and administration of basic health
Information sources ;
The key information sources are maternal cards and
child health cards, curative care registers, treatment booklets,
stock forms, drug and revenue registers, account books etc.
)
These various information sources serve several
services - community based preventive care has yet to be
addressed. Improvement in the public accountability of health
services and elected bodies is also needed, and users’s sense
of ownership of health programmes and their supporting
institutions must be developed. A major challenge is presented
purposes like direct service activities, management,
by women, who, up to now, have played only a limited role
supervision and monitoring. Such integrated use of
in the implementation of Bamako Initiative strategy - their
information ensures coherence in the Bamako Initiative-PHC
active participation is crucial to ensuring its effectiveness ,
information and management system. It provides several levels
and sustainability.
of control while avoiding multiple recording of the same
*
information.
hand in hand with the strengthening of managerial capacity
Efforts to decentralize health care management must go
at all levels and a reallocation of resources in favour of
Logistical Support
Besides monitoring of drug supplies, which has already
peripheral services.
*
Local capacity to purchase high quality drugs at reasonable
been covered in the previous article, transport is one of the
prices remains weak and the use of generic drugs still
main elements of logistical support. Under the Bamako
encounters resistance. Urgent action concerning cost-
Initiative national and provincial/regional directorates are
effective drug procurement and distribution systems is
provided pick-up vans to be used for various purposes like
necessary.
delivery of material like vaccines, pre-packed kits of essential
drugs, etc.; supervision and monitoring in the periphery and
pfor starting community health care centre activities and
• vaccination campaigns.
Some Reflections on the Bamako Initiative
From its inception equity has been at the centre of
the controversy surrounding the Bamako Initiative. While it
has been shown that even poor households are often willing
to pay moderate fees for services of reasonable quality,
policies and strategies for reaching the poorest of the poor
still await. In many countries, fees of patients who cannot
In the areas where the Bamako Initiative has been
implemented, it has contributed to making low-cost, quality
drugs accessible to the majority of the population. Community
managed health services have been able to generate sufficient
afford to pay for health care are waived off, but clearer
guidelines concerning the use of waiver and exemptions are
needed. Local health committees must be involved in the
planning and application of fee waiver mechanisms.
resources to cover total essential drug costs and some small
local expenses. For eg. in Mauritania, patients living in villages
A major obstacle to improving the efficiency of health
where the Bamako Initiative has been adopted spend on an
care delivery is the crisis in health personnel: health workers
average the equivalent of US $ 12 per capita annually
go for long periods without pay, their salaries do not keep
(including costs of transportation), compared with US $ 21
pace with inflation and they often go without in-service
in villages without the initiative.
training, support and supervision.
Yet, in depth evaluation of the Initiative conducted
by the London School of Hygiene and tropical medicine in
3
Besides redressing the above problems, two conditions
From Community Participation to Community Action
Parinche Project in the Light of Bamako Initiative
Dr. R. V. Banpel
FRCH is presently involved in imparting participatory
input in the community action process. This information is
training to tais (local women) at Parinche, a village in the
expected to increase vigilance of the people and thus
Saswad taluka of Maharashtra, on a wide range of subjects
accountability of the government officials leading to proper
such as health, non-formal education, public information,
channelisation and utilisation of resources meant for the
village libraries, veterinary care, repair of hand-pumps and
village level hand-in-hand with resources generated locally.
economic activities.
Community Financing
When we talk of community participation emphasis
is on participation of the community in the programme/
activity centrally planned by the intervening agency (NGO,
Government etc.). Though of a greater value than existing
vertical programmes, participatory programmes like the
Bamako Initiative infuse community participation more to
The Bamako Initiative has experimented with the
following alternatives of community financing : a) Fixed
consultation price; b) Direct payment of drugs; c)
Pre
payment scheme. Though each of these alternatives has its
own advantages a common flaw is that the very poor are
left out in such a system.
'
ensure the success of the essentally vertically planned
programmes and to obtain funding from international funders
and/or from the beneficiaries themselves.
At Parinche we seek to go one step further where
it is our organisation (FRCH) that participates in the activities/
programmes of the community and not the other way round.
The community takes the initiative in deciding exactly what
inputs it wants from us and how it is going to utilise them.
Within the community our emphasis is on interacting with
women as we feel they are better suited to carry out the
At Parinche the population has been grouped into units
of 1500 which is to be catered to by one full time and three
part time tais. Their payment is made on the basis of
opportunity cost i.e. each tai should recover at least the
amount that she would have earned from some alternative
work like for eg. farm labour wages. Services rendered viz.
drugs, immunisation, village libraries etc. will be charged extra
depending upon the actual cost.
Economies of scale:
task. Eventually we expect the community to be completely
As per the pricing system in Benin and Guinea, revenue
independent with the community evaluation of the work of
increases as the health service utilisation increases with the
the tais through village committees formed by the community.
danger that low utilisation will lead to non-recovery of even
Content of Training
The various broad areas (which have a high ratio of
the fixed operating costs. But since the infrastructure at
Parinche is to be used for many activites as mentioned above,
even if one particular service like health is not utilised enough,
inter-connectivity) to be covered in the training are :
revenue earned from overall utilisation of all activities should
* Health - human and veterinary
generally manage to cover the fixed costs.
* Environment - kitchen gardens, water, sanitation etc.
* Telemedicine and Grameen Bank
* Civic affairs - political and judiciary system
* Cultural activities - local culture with modern rational inputs
* Communication skills and participatory research methods
- participatory management, evaluation, survey etc.
Provision of information to the community about the
At present FRCH is taking on the responsibility of
helping the community for providing the finances but
eventually the financial burden will have to be borne by the
community itself through any method it finds convenient and
in the interests of the whole community. In our various
community level meetings, mahila mandal meetings, tais'
training sessions, the following suggestions from the community
various government schemes meant for them, the financial
have come up for financing the above activities :
provision for village development, the subjects under the
* Provision of funds from Panchayats
jurisdiction of local self government, rights and duties of
* Contribution from collections on various occasions at the
the people under Panchayati Raj etc, becomes an important
village level like annual fairs, Ganapati festivals etc.
Dr. Banpel, M.B.B.S. and L.L.B., is thePrinciple Investigator
of the Grameen Bank and DoE Projects undertaken by FRCH
FRCH NEWSLETTER, VOL X, NO.5, SEPT.-OCT. 96
* Direct house-to-house collection of money on an ability
to pay basis.
4
* Contribution from milk and other cooperatives
cost recovery of the health system will be broken. This, in
* Surplus income from activities such as ‘Grameen Bank’.
turn, could lead to a further erosion of purchasing power,
failure of community financing programmes, the downfall
Supervision
of the health system, and a drop in the level of health
As mentioned earlier, the logic of community action
protection. If these conditions are met, the health system’s
would hold true only if eventually the lais learn to function
reorganization in lines with the Bamako Initiative principles
independently and are accountable only to the community
will be able to contribute to the alleviation of some of the
of which they are a part and they are to serve. Such a process
health risks and to a reduction of infant and maternal mortality,
of community self-management would be activated by forming
even in the context of an economic crisis.
a village committee consisting of elected women members
of the Panchayat, mahila mandal members, local school
teachers (women) and senior female citizens from the
community. This list is subject to change according to their
availabilitya and the desire of the community. The members
of the community will be selected after consulting the people
in the Gram Sabha. The important functions of the Village
Committee are :
References
1. Knippenberg, Rudolf et al, 1990, The Bamako Initiative Primary Health Care :
Children in the Tropics, International Children’s Centre, Paris: 184-185.
2. UNICEF, 1995, The Bamako Initiative : Rebuilding Health Systems, New
York.
3. “Community financing or Cost recovery : Empowerment or social dumping",
June 1996 (Editorial), Tropical Medicine and International Health, 1, 3: 281-282
* Monitoring the activities of lais
4. Shaw, Paul & Ainsworth, Martin (ed.) Financing Helath Services Through
* Purchasing and pricing of drugs
User Fees and Insurance : Case Studies from Sub-Saharan Africa, World Bank
* Fixing charges for community services like immunisation
of cattle, village library etc.
Discussion Paper, 249, African Technical Department Series, 1996, World Bank,
Washington.
* Deciding upon variation in charges for different
beneficiaries according to ability to pay.
5. . The Financing of Community Health Services in Sierra Leone, Bamako Initiative
Technical Report Series, 1990 & 1991, 3 & 8, UNICEF, New York
Openness is the key word in community self-
6 Bennett, Sara & Manengu Musambo, Report on Community Financing and
management. The village committee will periodically hold
District Management Strenthening in Zambia, ibid, 1990, 5
meetings with the community to inform them about the
7. Parker, David & Rudolf, Knippenberg, Community Cost Sharing and
various activities undertaken by the tais. The community will
Participation : A Review of the Issues, ibid, 1991, 9
be encouraged to give a continuous feedback on the work
8. Hanson, Kara & Felix, Chindele, Cost, Resource Use and Financing : A Study
of the tais which will act as an effective tool of participatory
of Monze District, Zambia, ibid, 1991, 12
evaluation of the work of tais.
9. Pangre, K.A., et al. Revitalisation of the First Referral Levels of Care (District
\
Hospital), ibid, 1993, 15
Conclusion
10. Tibouti, Abdelmajid, et al. Household Surveys of Health Care Demand and Health
Looking at the Parinche project in the light of the
Bamako Initiative the following improvisation in our approach
I is evident :
Care Expenditures : A Practical Guide, ibid, 1993, 17
11. Lerberghe, Wan,
et al. Quality of Health Care Provision in Africa Through
the Bamako Initiative : Problems and Strategies, ibid, 1993, 19
* Parinche project does not look at health alone
12. Project Management Team, The State of the Public Sector Primary Health
* It is a women oriented programme
Care Services, District Sheikhpura, Punjab, Pakistan, ibid, 1995. 31
* It is primarily a social experiment
13. Guyon, Agnes, Cost, Resource Use and Financing of Health Services in
* It has a possible long-term high-inlensily coverage
Bangladesh : A Study in Two Thanas of Faridpur District, 17-27 April, 1994,
* and last but not the least, it is a process of mutual learning.
ibid, 1995, 32
14.
( With inputs from Seema Deodhar )
Hanson, Kara & Gilson, Lucy, Cost, Resource Use and Financing Methodology
•
for District Health Services : A Practical Manual (2nd ed.), ibid, 1996, 34
( Contd. from pg. 3 )
15. Kuchlar, Dr. Felix involved in Benin Bamako Initiative Programme, Personal
are indispensable to the success of the Bamako Initiative :
communication, Swiss Tropical Institute, Switzerbnd.
maintenance of the population’s purchasing power and
16. Mupka, Dr. Simon, Personal communication, Zambia.
continued payment of salaries of health workers at sufficient
17. Malaba, Dr. Moses, Medical Officer, Personal communication,
levels. This needs a stable political situation with sound socio
Ifkara Centre, Tanzania.
economic development aims, particularly sub-saharan African
18. dMama, Dr., Personal communication, Camaroon.
countries. Without these two conditions, the fragile balance
19. Mefsin, Dr. and Fassil, Dr. Medical Officers, Personal communication, Ethiopia.
between the household’s ability to pay for their health and
20. Tekle, Dr., Personal communication, Ereteria.
5
•
FRCH NEWSLETTER, VOL X, NO.5, SEPT.-OCT. '96
A ‘Burning’ Issue
Hospital Waste Management
Shriniwas Indapurkar
Every city in India is dotted with private and public
Waste Treatment
hospitals, which treat hoards of patients daily. Neither any of
the hospital staff, nor the endless stream of patients they cater
to, seem to give a thought to the waste generated in the course
of their treatment, oblivious to what a health hazard this waste
may become. Hospital waste is potentially dangerous, even fatal
at times. Yet, unlike other aspects of the working of hospitals
Few hospitals bother to treat such infected waste and
dispose it in a manner as to render it harmless. Otherwise, a
large part of the total hospital waste finds its way untreated
into the municipality bins. There has even been a case of
dissected organs being found near bins placed in residential areas.
like the integrity and efficiency of doctors, the (un)hygenic
In India and other developing countries many scavengers
conditions in the hospitals etc. which come under public
collect useful reusable material like knives, plastic containers
scrutiny, the vital issue of disposal of hospital waste seems to
tubes etc. This garbage helps them to earn about Rs. 10 to Rs. 12
be ignored by most.
per kg. The syringes sold therein maybe reused, often without
Why Hazardous?
Almost every operation undertaken in an hospital
properly sterilising them, making a mockery of the stress upon
using disposable ware for preventing cross infection. In Delhi,
it was found that the cotton used in hospitals was bought from
involves the use of cotton and/or bandage to wipe and dress
the scavengers at wholesale rates by those making quilts and
wounds. This used cotton gauge or bandage inevitably finds its
mattresses. Thus, while on the one hand hospitals cure patients
way into the hospital garbage carrying with it hordes of germs
of diseases, on the other hand they are also conducive to
and infected tissue. Same is the case with used operation gloves,
spreading them.
syringes, surgeons knives, scissors etc.
Incinerators
Allopathy believes in operating upon and if necessary
removing any organ within the body that does not function
properly. These diseased unwanted organs also form a part of
hospital garbage.
According to the Supreme Court order of 2nd
March’96, all hospitals containing more than 50 beds have to
provide for incineration (burning) of hospital waste. The
Environment Ministry has also dictated that all hospitals having
Hospitals are frequented by people with various
30 beds or a turnover of 1000 patients per month have to make
diseases. The body excretions of such patients whether saliva,
the above provision. But all these laws remain on paper and to
blood or excreta are infected with germs. If left untreated and
date only a few large hospitals follow this practice. For
exposed these germs enter the atmosphere infecting other
example, in a study conducted in Delhi, where the rate of errant
patients and hospital staff.
Pathology laboratories contain samples of stools,
hospitals including large ones is very high, it was found that
only 20% of the hospitals have a provision for treating their
urine, blood etc. which are often infected and also germs and/
waste. In some hospitals including a few from Pune, the waste
or viruses cultured in the laboratories in the course of various
is burned in the open. Moreover, in many hospitals which
experiments. The chemicals used in such experiments as well
provide incinerators the temperature therein can be increased
as the infected tissue samples etc. are disposed off into the
only to 400°C or 500°C when in effect, for burning the waste
garbage from where the germs spread elsewhere. Contaminated
adequately a minimum temperature of 1200°C is required.
plastic ware used in the laboratories is similarly discarded into
the garbage bins.
Such practices of burning the waste in the open or at
temperatures much below the required level lead to the escape
Unless all such hospital waste is sterilised and
of toxic gases into the atmosphere and increase the atmospheric
detoxicated, prior to disposal, it could be instrumental in
pollution posing a grave danger to the nearby residents. A
spreading infection and even starting many epidemics.______
voluntary organisation ‘Srushti’ which had conducted a survey
Shriniwas Indapurkar has done his postgraduation in
of hospitals in Delhi reports that burning the waste, especially
Environmental Science and is presently working as researcher on the
if done in an improper manner, was not going to put an end to
SACHETT project of FRCH.
the problem as it merely changes the physical or chemical
FRCH NEWSLETTER, VOL X, NO.5, SEPT.-OCT. '96
6
composition of the waste. The toxins are released into the
West itself the realisation is spreading that burning waste does
atmosphere in fluid forms which pose an even greater danger
not offer a solution to disposing it. Only the form and chemical
to the health of the people.
composition of the toxic substances change, often for the
In a similar study conducted in Denmark it was
worst.
concluded that while the total hospital waste would amount to
A better alternative would be to train the hospital staff
one percent of the total municipality garbage, the same waste
to take precautions in generating a minimum amount of waste
when converted into toxic gases like dioxin forms a staggering
in the first place. This way, the problem is tackled at the source
30% of the total atmosphere. Other heavy gases like Cadmium
itself. Whatever waste is then generated should be managed in
are also emitted in the process. This shows that burning the waste
a proper manner.
cannot be an answer to the problem and alternative less harmless
According to ‘Srushti’ the first step in waste
techniques have to be evolved for disposing off the waste.
management would be to sort out all the garbage into various
Developing countries like India have passed laws for
categories like :
incineration of hospital waste. But for complete incineration
to take place a certain minimum quantity of waste is required,
a condition which many small hospitals are unable to fullfill
as only a small quantity of waste is generated at any particular
• time. Incineration of such inadequate quantity of waste prevents
the waste from being burned fully and generates many toxic
by-products.
* Garbage directly reusable by the hospital like syringes,
knives etc.
* Other recyclable garbage
* Garbage that should be incinerated
* Garbage that should be treated in some other manner to render
it harmless.
When the waste is burned down to ash which is
It is important that all the reusable material from the
carelessly thrown into public bins or even out in the open it
garbage be adequately sterilised before usage. While reusing
again adds to atmospheric pollution. Unfortunately, there are
the material helps to tackle the problem of waste disposal it
no proper guidelines for the disposal of such ash either at the
also reduces the cost of medical care. For eg. reusing the
national or the international level.
cathodes involved in heart surgeries significantly reduces the
cost of the surgery. In dialysis too the same case holds true.
Who Bears the Brunt?
Thus, generating minimum possible waste, recycling the
As explained earlier, hospital waste carries various
germs with it which can spread many diseases among the
reusable garbage and detoxicating the remaining waste with
appropriate methods is the key to hospital waste management.
people. The gravest danger is posed to scavengers, many of
whom are small children, who handle the waste to separate out
References
reusable material.
1. Martin, Max and Dutta, Madhumita, May 31, 1996, Hospitals : Management
Many stray or pet animals are found to frequent the
@ garbage bins in search of food. These animals can also get
infected due to the various germs contained in the garbage.
Morass, Down to Earth.
2. Coppinger, Phillips F., May-June 1996 and July-Aug 1996, The Incineration of
Infectious Waste : A Threat to Public Health, Part I & II, MFC Bulletin.
Moreover, they can get cuts with the infected needles and knives
carelessly thrown into the garbage which also fester with germs
( English Translation : Vaijayanti Aphale )
□
which arc spread to other areas where the animals roam
about. If the animals are adopted by any family then that
family is directly exposed to the germs carried by them
FREE ABSTRACTING
!
from the garbage.
The contents of this newsletter may be
The garbage clearance system of the municipality is very
abstracted without prior permission.
haphazard. Overflowing public bins are kept exposed in
residential areas for days which allows the germs to multiply
and spread and infect the surrounding residents.
!
However,
we
would
appreciate
acknowledgement of the source and
copies of any abstractions
Hospital Waste Management
Today, hospitals in India are aping the Western model
of disposing off waste by burning it in incinerators. But in the
7
The views expressed in the articles are those of the
authors and not necessarily those of FRCH
FRCH NEWSLETTER, VOL X, NO.5, SEPT.-OCT. *96
Hldvifc 81
s. y-1.yd.3nf-ear
3llylt a H44, HRe ch ner A ?64 aiet R3 HfTd
WRaR fraj A sfd URUH JIT che # &lWe A 11 stfg
w-eica a ufaculench, sicH16c5 a 5olv ch 34 He dald Hel
Ah, chfo-laf a H44, ftA 8a d
ch83 a fey, Hlcfc a a cet-l ch us at mdt ah
t At w1-3ud H gam chhl did ftA a A agidl A ad
H
chih qr Hvg? 61 vild
3 feg, fsigsi ch1
$H ci 4, ft a ART sudd Hfaarof chT MP 3614 cht &THd
E1933 Bfsche aieivi A sHRt ah
aff at 1 Hdfc al at ceu-T, * chh&t &RT f n 8l4aT?", ‘t
SfTeUra fnt g SicF3, srafch tl ch-f * naw suscich
& ferg afadl tale auHle!’ W JTaRr at 1 sH JqaRo d
al
JHHHZ, s--3aa, faal-d yulief chl suaMT, t12 a Uch
At af tieof A ale!’ A wI3 A avis A ya ST43, wTasc5
sobl $ qy H shar vl-T AT I Heuc ^o,ooo ah 3liqict W{ Uoh
Fl AA A a!H a A cheRar A 3llc24c5 age a4 A A
Wrasch tal o-s a 9Q fatzi ald Bdief ch F19-T cl *
Jlthe z 11 HO A, &F3, ada 5u A ftA sie? ceeig
Jaa- ar l * ch& &RT d ns aqau at UhHI SHtheidl
cr, 3-14 a4 Tei SCT6?U A, chharar A RZT9T A
45 at s GH, fa-T coft qefur cT gap fd a a— e aht
ferar }i
FHR tie a fg, a A uffei 8 At a A *Rd 1 gt3
tre titoi w afa a- fey, FT a fafeHl adeld W
3E5i A, aA ara wA sttROIT * 24 sfesm eh r^A
alcufucl RR sera TAT a l as a qsu-Hal ko ch f, sic
w Afta anfchl Arnaa Eid t, fa EI to- 3 &lHT sner
4 H- 99c A Ar als. A. UH. qrr. JR./ SlTs.H.H.3R.
cha 4 H 9869 #, FIT
st qfclo A aleRT4T a i $H
6, Hldwfch aa A dar, ?H{CR, HETHferchT ar AA ch &RT
39cc calt vild t 19T6?T A AA A aedi ss Blidid A quis A,
qiA, H1h-HWls a 3-4 RoMt Hari qr 3lcufuch aaid us ?6T %
HIse A JHlqsficid A, s s* A7! a Mcicbl 3, afo 394 2QT
Ar A hA dar, Rid 41A 3Hcic A qrA t, susufzzur A ?64
A, che Ar cs *-H{cl? Ho-i 4 A Hefsi sa % i qas
ald AA A del-I A, aA AA do afch ugud % 1 $16? A,
d, 1124 W J94 Hchel Ro seid (AAA) dl ahec 3.4
hiAAAf Aa qr AA ale tef, afache aHRa 3 ^ara % fig
HfeAl A dr cee t, (3H 3 A afAl A,3.9 ufl Hldofc
gaa wal qr Aar % i a5 irf, aqaf chhuRar Ar SHHsud
an a 9.xqft§iaftA^aqT^A?laT t), qr arrt^i ARt^j-^
Hfaari ald kee Ara, HETfeichT A qard-i ar fse-Ra Ar
a af Z After s- qr ahee 36 %, gHf At Ha 4,
tfsche aievi A v §3, &fich Hara a ald as-as arctle
t12 qr Hche aq seHle a 6 HfTRl de Aa 3 al A, fTg-
qr Aar % i s gferarei al aqata, IT63 a AA A 353 ald mar
5gJ a af &R After w= W c k, A ft) aga afuc At
srt soar A vild %, qr A ata, as AA 2 saw chl A 3
soclv-c t (^ 6 HfRl 4, chde 9.3 HfAk Hdwsc 8 qr
cifTQT ci, JcH3 AA A frst 55 34ET A vild 11 H12
was 3.9 Hfrl ftA ax qr Ele %) 1
AarA
qa ae Aa 3 8 A, $- ne Ar fsrasi 8 SFllw
A auC al aleft awA al, rr-f ftarrft, * am©
gHfcAT, Hicwifch 8 ch f, FrO A aaku <6 5H
qfal qfclo qr ftA Aa
ar^ A
A aar 11 ara A
feg
54, zq qe A WI- a3 ah feg, Su 8 ad ng chlcba cRI
ar- At g- AA oI z s l
ad t, ter
A
Uo HTHTu fusoctich
saw shar ar Hchdll % l CHT 5^11 TRIT % ft) HTru suscich as
hAt cr did, Uoh Jlcufach ch-iga a sozoTft ufa A ace
seg w 815- H chl hecil, ferA *, 37/ aiddfola tino-
HiSwsc 83, a-f dHIH AAA ch aidus, 3- cfbaf
At titaTei 2 aA qr Aar % 1 FT A 56 qfezclur 3 ena
A, $e 88 co, t12 eiHle 39«c child A H8H %, Rn A ar
^nar A, wTesch tle AA *goxfearkifa-encft
A ftA FT AarA dob ugu aA t ar ss ftA Aa A rarsa
Hfisif dh, cex A afe c fig Ju A as ng chlchH, we
Bud car qr aa^A A tr chi-T use t1 &l: Hicuifch Aa
A, 29T A cl’ 5 anfch Alfar a &RT Hvdd ain A 311q24chel
5. (I. ye. anfar,
a ze, qonyu.am. a
9 on.ef.ge. * tfc Huff, gcezr a
eTez s 8ls #
67876-787 cprf fd t / 35a
fvR a ertere 5^7 3-h arf
f4, 34 *a RoR a ^*HT 3ah tareez
af 9Tlf^r tl
%, a ft) chHi ara A i
(f^t 3lgee: tfia sfaeaa)
□
Edited by Yaijayanti Aphale with assistance from J.S. Puranik. Produced by the Foundation for Research in Community Health, 3&4, Trimiti B Apts, 85 Anand
Park, Aundh, Pune - 7. Registered under the Bombay Public Trust Act. Printed at Abhyankar's TypeServe, 9 Brahma Siddhi, Prabhadevi, Mumbai -400025.
The F oundation for R esearch in C ommunity H ealth
NEWSLETTER
Vol. X, No.6
Nov. - Dec. 1996
Inter-linkages Between Socio-economic Factors and Access to Health Care
Maternal and Child Health -1
Anuradha Gupte
The health status of the people is increasingly being
inter-linkages between various factors affecting health are
considered in a holistic sense as an integral part of their
strongly present and can be easily demonstrated in maternal
socio-cultural and economic background. Various studies have
and child health (MCH).
ascertained the linkage between the deprivation of
opportunities for decent living and poor health. Deprivation
Economic Status and MCH
does not merely refer to external and systemic factors like
unhygienic conditions, pollution, lack of adequate health
delivery systems, lack of adequate nutrition etc. but also the
individual’s capacity to take advantage of these externalities.
This capacity is determined by resource constraints like
income levels as well as socio-cultural constraints such as
education and general awareness levels, freedom to take
decisions etc. Thus the deprived would generally include the
poor, the socially backward classes and women.
|
The poor often experience a higher morbidity and risk
for early deaths than the rest of the population. In the global
perspective, poverty is the most important determinant of
poor health. It has been estimated that more than 75 per cent
of differences in health between countries are associated
with differences in income. Studies show that the so called
tropical diseases are rather diseases of poverty and non-
communicable diseases are diseases of limited rather than
excess affluence. In this context, equity oriented economic
It is important to note that these socio-cultural and
growth becomes essential.
resource constraints are inter-linked in a manner such that
the absence of one factor in many cases reduces the impact
of the others. This is especially true in the case of women
who even when economically well off, are usually
incapacitated in socio-cultural terms to take maximum
advantage of existing benefits in all fields including health.
Since in early stages at least, the child is
dependent upon the mother, the socio
economic
background
of
the
It has been observed that poverty entails poor health
not merely due to lack of economic resources but the negative
impact of other non-medical factors like food availability,
awareness levels, environment, sanitation, quality of
drinking water available and gaps in the application of
knowledge available that are generally associated with
poverty.
in this issue
women
automatically becomes an important variable
in determining the child’s access to health care
in quantitative and qualitative terms. Thus
♦Maternal and Child Health - I......
Anuradha Gupte
♦ Reproductive Health Problems of
For instance, milk cooperatives have
been used worldwide as a mechanism for
raising the socio-economic status of families
Rural Women -------------------------.-........3
involved in the dairy business. The impact
Seema Deodhar
of this phenomenon was studied in the Delhi
and is a researcher on the Public Information Project
♦ Gramin Mahila Aarthik Swawalamban
milk market. Evaluation studies by F.A.O.1,
at FRCH
(Article in Hindi
Anuradha Gupte is a post graduate in Economics
Dr. R.V. Banpel
U.N2.,and
W.F.P3.
show
that
milk
consumption in this region has in fact declined. This is because
acceptance of family planning alone by poor populations
milk cooperatives increase milk demand increasing milk prices.
has not necessarily resulted in striking improvements in
Hence, producers prefer selling all the milk and substituting
child health and better nutritional status for their children.
it with cheaper calorie rich foods. Also, inter- community milk
Therefore, it is obvious that fertility programmes cannot be
exchanges decline and families who continue to remain non
a proxy for programmes for direct improvement of
producers have to pay more for milk /milk products.
socioeconomic and nutritional status. India’s health and
nutrition drives are far from complete; therefore, it is not
Where sale of milk to co-operatives replaces milk
surprising that the family planning programmes have not had
processing activities at home such as conversion to “ghee”
the desired impact. Much greater emphasis must be put
and home consumption, female employment and nutrition
on the mother, on improvement of her physical state, her
in fact declines.
economic state, her health and nutrition, and her education.
In such cases, whether sufficient milk is retained
for infants, expectant and nursing mothers, would depend
Dynamics of Socio-economic Status (SES) and Maternal
Health
on whether awareness levels of women have improved.
Observations prove that cash incomes are not always spent
SES
INTERMEDIATE
in the most desirable way and that sex biases in nutrition
do not immediately disappear.
Income, Education
In Guatemala, the association between malnutrition
and infectious disease for the rural population was studied.
Health and
infant mortality rates and incidence of low birth weights.
The study concluded that improved economic conditions
(
Pregnancy,
reproductive
Complications,
behaviour
Maternal
mortality
It was observed that improvement in nutritional status was
not associated with improvement in health indicators like
OUTCOMES
FACTORS
Access to food
Health status
Status of women
Access to health
positively affect nutrition but do not appear to modify health
services
in the absence of educational and health activities that
Unknown factors
are integrated into community development programmes.
With reference to access to food and nutritional outcomes,
factors like lack of access to resources, inadequate education
If SES is to affect maternal mortality, it must be
and intra household food allocation patterns favouring boys
shown to have an effect on at least one of the intermediate
and adult males have been pointed out as significant factors.
factors, and this chain extended to one of the three outcomes.
The three outcomes are sequential i.e. one cannot die a
Family Planning and MCH
It is often stated that female and child mortality and
maternal death without first being pregnant. The three basic
questions regarding influence of any factor are :
0
nutritional status of the child is likely to improve when there
Will it affect the incidence of pregnancy ?
are fewer siblings. Family planning can reduce the total
Will it affect the incidence of complications amongst
number of pregnancies, thereby decreasing a woman’s lifetime
pregnant women ?
risk of dying in childbirth, and it can reduce the number
Will it affect the outcome of obstetric complications ?
of deaths due to high risk pregnancies. Although, family
planning does not make any difference to obstetric risks,
Anything that reduces fertility will reduce maternal
it makes an enormous difference to the number of maternal
deaths. Direct obstetric deaths may occur due to pregnancy
deaths. If women have half as many babies, there will be
complications, delivery complications and post-partum
half as many deaths related to pregnancy even without
complications including abortions. Indirect obstetric deaths
any improvement in obstetric services. In addition, by
are those due to existing medical conditions, made worse
preventing unplanned and unwanted pregnancies, family
by pregnancy or delivery, and include malaria, hepatitis,
planning can help decrease the number of women who risk
anaemia and rheumatic heart disease. In the developing world
their lives seeking unsafe abortion. Lower birth rates are
25 per cent of obstetric deaths are of this type. The specific
also associated with increased child survival. Whatever the
medical causes vary with the socio-economic development
explanation for this phenomenon, where child health is
rather than with geographic or genetic factors.
concerned, several studies have shown that greater
FRCH NEWSLETTER, VOL X. NO.6, NOV.- DEC. *96
(Contd. on page 7)
2
Socio-Cultural Aspects
Reproductive Health Problems of Rural Women
Seema Deodhar
FRCH is implementing a project at Parinche, the main
the deeper issues concerning their medical problems.
focus of which is on training of competent local women
(tais) in health and related aspects to function as ‘development
Women complaining of vaginal discharge are easily
workers’ with a focus on basic (primary) health care at the
castigated for not maintaining proper hygiene discounting
village level.
the fact that in areas of water scarcity women often have
to carry water for household use over a distance of 2 km
During our interaction with the women in the training
or more. This leads to rationing of water for all puroposes,
sessions we got an important insight into the health problems
especially bathing. Also, there are no private bathing facilities
of the rural women and the various factors inhibiting their
in most dwellings, thus out of modesty the women cannot
ability to address these problems.
disrobe before taking a bath. Moreover, there are cultural
)
inhibitions about touching the genitals which prevents them
Initially, the women were reluctant to openly discuss
from cleaning these parts.
specifically gynecological problems. To get them talking we
began with discussions on general health issues and women’s
The notion of menstrual hygiene too is complicated
role in the society and secondary social status - a subject
in the context of social taboo on menstruating women. We
which generated much interest in the group. Through our
found out that all the female members of a family use the
discussions it was revealed that the rural women blame their
same set of rags as sanitary napkins. Since the rags are
low social status on their perceived limitations of the female
considered as extremely polluting they are kept buried under
body showing their acceptance of the logic of biological
a stone in the cattle shed under unhygienic conditions. It
reductionism. This gave us the opportunity to take the
is obvious that using such clothing will lead to repeated vaginal
discussion further by dymystifying the woman’s body which
infections.
was perceived in such negative terms. Through innovative
means we got out their opinions about various natural
Given this background, it is clear that mere
phenomenon regarding the women’s body. For eg. when asked
symptomatic treatment is not going to be enough as the
about the menstrual cycle we were surprised to learn that
complications will persist and become chronic if the basic
they regarded menstrual blood to be spoiled blood flowing
social conditions remain unchanged.
from the intestines. The fact that only women undergo this
Another important example of social conditions having
experience had further degraded the female body in their
-yes. Through diagrams, demonstrations on a female child,
medical repercussions is the various cases of prolapsed
domesticated animals etc. we explained to them the proper
uterus. It is shocking to realise how widely prevalent this
science behind the various processes in the female body and
condition is among rural women even at a very young age.
cleared many of their misconceptions. Thereafter, discussions
One of the main reasons for this is marriage and subsequently
concerning women’s sexuality and reproductive health became
first pregnancy at a tender age coupled with hard physical
free and open.
labour. Quite often the loads of firewood, water and food
grains carried by them weigh more than their own body weight.
It was clear through our discussions that the medical
Women of remote hilly hamlets in drought prone areas are
problems of the rural women are in many cases a
the worst affected. The women are made to work
manifestation of their social status and the conditions they
approximately from six years of age with the load increasing
live in. These socio-economic conditions are not taken into
proportionally with age. The women are not spared from this
consideration by health providers leading to an insensitive
job even in pregnancy or post partum. After delivery they
attitude during treatment. Victim blaming is common when
are forced to return to hard physical labour within 15 days
in fact the providers needed to at least understand if not address
if the child is a female and within a month if it is a male.
Seema Deodhar has done B.Sc Nursing and conducts health
training sessions as part of the Parinche Project of FRCH
3
Some of the traditional delivery practices like too much
pressure being applied on the abdomen of the partiurating
FRCH NEWSLETTER, VOL X, NO.6, NOV.-DEC. 96
women by the birth attendant add to the problem. The other
of water over large distances results in over-utilization of
predisposing factor for this condition is nutritional deficiency.
specifics sets of muscles in single directions. This leads
to isometric imbalance causing body ache.
The side effects of uterus prolapse are offensive
smell, heavy vaginal discharge and painful scratches on the
Osteoporosis is prevalent particularly in areas near
uterus. These side effects often led to rejection of the women
any milk cooperative. This is because all the milk is sold
by their husbands. Many women with prolapsed uterus are
by the rural families to the cooperative, since this is the
sent back to their maternal homes.
only income generating source for many families in rural
areas, leaving none for domestic consumption. Where as,
An example of a chain reaction of inter-linked
in villages without milk co-operatives there is a chance that
problems which lead to the victimisation of such women
the women might consume some of the milk left. Clearly the
can be described in the following case history. One of the
law of economics has taken precedence over family nutrition.
rural women with prolapsed uterus experienced great pain
during sexual intercourse. To avoid sex she pretended to be
Other nutritional deficiency diseases like anaemia and
possessed by divine spirits and periodically went into a
night blindness are common in the village areas. In case of
‘spiritual trance’. During this phase she would advise her
pregnancy related night blindness women are recommended
husband to keep her body ‘pure’ for the Goddesse's entry.
The husband respected this ‘divine injunction’ and alternatively
21 days of carrot consumption. Fifty years ago carrots did
form the staple diet in this region. However, poverty and
ignorance along with a change in their traditional lifestyle )
used this as an excuse to enter into a second marriage. Now
the ‘possessed women’ is sent back to her mother’s place.
Even though such strategies are initially consciously
developed by women, after a point the women become
psycho-somatic and hysterical. Even if medical intervention
is sought few medical providers will link her mental stage
to her physical state of prolapsed uterus.
Sex itself becomes an issue of suppression and
occasionally, torture for the women. During our discussions
with the women it was revealed that their husbands insisted
on intercourse within few days of delivery without giving
enough time for their bodies to heal. No wonder dyspanuria
is a commonly voiced condition among rural women.
Ironically, though it is common knowledge that women have
hardly any say in their sex life, women with multiple
pregnancies are often scorned by health providers in words
due to commercialisation has led to a decrease in the nutritional
value of their food intake. Though palak and other types of
spinach are now cultivated along with carrots, their consumption
has declined as they are produced purely for the market.
Where mental illness is concerned, the feature of all
pervading patriarchy is now commonly accepted as an
underlying cause of most cases of mental disturbance among
women. Severe limitations on opportunities to express one’s
personality and great restrictions within the traditional setup
leave no outlet to women undergoing stressful situations.
Widespread prevalence of various types of depression
indicates social factors rather than a purely genetic one to
be mainly responsible for occurrence of mental illness.
To add to the problem, the availability of psychiatric
like “Tenvha Maja Watai Hoti Aata Ka Radata (You should
aid is almost absent in most rural areas. In a particular casy
a psychiatrist would visit a small town situated 20 km awa,
have thought of the consequences before indulging yourself)”.
from the village of the mentally ill person on the 1st Monday
of every month. In case that day was a public holiday, one
Other health problems commonly experienced by rural
would have to wait until the following month for medical aid.
women- piles, body aches and backache, hyper acidity, urinary
tract infection etc. can also be traced to basic social problems
The sheer number of suicides among young brides
points to the suppression of women and limited options
Constipation is endemic among rural women for
available to them in the conventional system. It is no surprise
various reasons like lack of green vegetables and fibrous
therefore that mental instability is widespread in Indian
food, limited water consumption and retention of stool until
society at all levels. Male mental illness too is widely
dark due to lack of closed latrines. This chronic constipation
prevalent but usually conveniently categorised into substance
often leads to piles.
abuse, wife beating and general violence.
Body ache and backache is universally found among
A young school teacher was facing much mental
rural women. The nature of their labour in the fields and
torture from her husband and in-laws - all aspects of her
domestic chores including gathering of fire wood, fetching
appearance and behavior were criticised - chiefly due to her
FRCH NEWSLETTER. VOL X. NO.6. NOV.- DEC. 96
4
family’s inability to pay dowry. After her first child birth
for 4 to 5 hours since it was night and only the following
her infant son was separated from her and she was constantly
morning was she was taken to a PHC for treatment. The
subjected to insulting behaviour. After the second child birth
PHC doctors merely removed thorns from her back and
she was made to resign from her job and then sent back
dressed her wounds. They conveniently accepted her husband's
to her mothers home leading to separation from both her
statement that she had accidently fallen on a pile of thorns
children. Needless to say, the husband remarried and the once
though she sported other injuries and the thorns were embedded
bright girl who was highly qualified according to village
deeply into her flesh. Subsequently, she ran away to her maternal
standards (SSE. DEd) with several accomplishments in
home, where she was fortunate to be accepted back. Her parents
drawing, rangoli, acting etc. lost every thing - her motherhood,
later faced difficulty in obtaining divorce for the girl. Had proper
job, family and self respect with no apparent way out.
records been kept of her injuries in the case paper at the PHC,
the legal problems would have been minimised.
)
Another case can be cited of a young girl
•
displaying signs of adolescent stress. Her parents got her
Besides insensitive attitude of the health providers
married at the tender age of thirteen. By the time she was
the other main reasons for women not reporting their
twenty she had already mothered four children. The sheer
reproductive health problems to health care providers, as told
stress of repeated motherhood and increasing duties at such
by the women are :
a young age took a tol on her mental balance. She was
1. Women not recognizing such conditions as problems but
propmptly thrown out of her husband’s house while the
as a necessary fact of being women.
children were retained with the father. She returned to her
2) Due to inhibitions or lack of vocabulary to describe the
mothers’ house where she was treated for her illness, but
condition.
due to being over-burdened with domestic duties she relapsed
3) Inaccessibility of services due to PHCs being situated
back into her illness. Today, she is a women of 42, surviving
at long distances.
in a mental hospital.
4) Subcentres are manned by ANMs who often neglect their
duties for various reasons including lack of training or
Mental problems which are easily curable at the early
stages are ignored,
building up to neurosis and psychosis
later on. At the village level depression is not considered
sensitisation to cope with these issues.
5) Private practitioners charge fees which are too exorbitant
for rural women.
as a disease deserving medical attention. Women suffering
_
"
from depression are often chided and berated for neglecting
The various points revealed in our discussion and the
their duties which increases their mental tension. They are
particular examples sighted here make it obvious that health
unlikely to find sympathy or proper treatment in their maternal
is not merely a medical issue. Socio-economic, legal and
home either. Medically, depression, if attended to promptly
cultural dimensions are equally important in health care. What
and regularly can be cured. Presently, in the rural society,
is needed is conscientisalion of all health providers about
such regular treatment and sympathetic case handling are
the specific social issues surrounding the health problems
almost absent. Therefore acute incidences become chromic
and lead to incurable disorders.
especially of rural women and should become a part of their
Health care providers also have to be conscious ot
entire team of functionaires. Alternatively, the village women
the legal aspect of the cases they treat. Though touted as
themselves need to be trained to collectively recognize and
formal syllabus. Clearly, the doctor alone cannot attend
unassisted to all these issues. It needs combined effort of an
accidents, many of the physical injuries women carry are
attend to their health care needs. In this context the concept
actually due to wife beating, rape etc. In such cases it becomes
of holistic health care has great relevance as it lakes into account
the health provider’s duty to note down the injuries which
all these factors influencing health and health care.
□
could be crucial in getting a divorce or proving a rape etc.
as the case may be.
To cite an example, a girl who was married at the
Latest FRCH Publication
Panchayati Raj Information Resource Book
1996, 156.
age of 15 into a family selling alcohol was violently beaten
up by her husband for not attending to one of their customers,
though the latter was sexually harassing her. Her husband
and in-laws then flung her on the firewood which pierced
all over her back. She was forced to lie down in that condition
—
5
This is a directory of NGOs working in the field of
Panchayati Raj and
gives information on the address(es).
contact no(s)., nature, area(s) of expertise and language(s)
of communication of these organisations.
FRCH NEWSLETTER, VOL X. NO.6, NOV.-DEC. *96
MT)U Hfscil 3 Ydidcias
ST. vids al0a
yfl te l? teit
k
nRiary ten
nt
afucbe t1 HHEqT3 c arjo R? W ty cl" STU 6
HeisaI oIT HCbeIl tiHiyffm^Tmlte
63 H4% 4 Uoh 37081 ai Uoh Hfe te t, wi te 3" a gfaa
alf? n He chid 81
kR W FT
dch ch uRdie 4 s safd Roisi at 3149acdl sid t,
a mf a- HI=f1c5, anfc a wiessec nffefar t GIvPT 82
3rich
dh =6 s Hche % i se telth 3 q. &. tr.
< Ele l1
cp yo sie
a Y=z alegel a ufe tet # Ueh Hhfhd tew 3TP ch?4 kg
wiefa sohal l sH qRalvH a nffafar 4 ne ch disa cp
HI NfTerUr, 6--H=-IT, * anurfc fre, teN ald-lles,
HTHRU thil H ?T vild % 3 3-chl ter U2120
saH q afs4H
57 ‘aud H56‘ * R- te a
a 9 o afd sid 8 1
sie wdan a teN HfseI anfcb FIdcia ww AT!" afh’T
WRaR at Uch 8 HetT, H45 ah HePT a- Hete % i Uo aldif"
9THc s i
cischl 446 al HeeT an Hohal l, W-d ag 3U te ch ft ter
dne 29 a Heo ach aiciei-I & HT6u W aad st
u =f li
uRal-I cl He sesq me a HfeT3i ah 3ley qud 3 *"
H45 ch tinfor chid Hiu R R tdd: R H85 BTdjviAT ch
57 HIs Heuch HGPI ch 5. «/- a =H add ch aMeH ter
31149446 II
WicHle- c-T 81
HP4T 3JUnf add ah {$4 chift 1 siole Hodl 11 455 a
a 9 fia 988% chi, usd * 96 fter
a-n ch a H&A ch JW1-d chis • 5o Hee4 5. qoo/- dc cl
14 a JR917 4 cii 3 5Hchl $8 ferny ten 1 UHT AHafgr ch
3U d Hodt 11 qas 6. ^ooj- chi 3u aga chh Jdid sid l,
Hschl? qei 3 H $e ufe agHaf ch ci?U 53T srchl soh
Wg sHH HHIv H HfeT3 ch RR cl GuT fa 1l JHR W,
WRHH14- 81 TAT y aT $8 faz Q-gi ah ud sabeol chin ald
5. 400/- chT 3" vitra al { chh 3 ter a-io 34 ch 3-4
qol=z a H a a4a a ai2O i g8l, w for sleurfach affafc
ald # vsd 11
aq 5H
a a s-o mffafaar * Hesre at l
af H5 4 Uoh Hie aht 3laf q ch 5ft It a HcBId
suf 958ld ch c d % H&- n 6H- t144 HH614 c HT
3qob #- rfud ch33 W fasiq a- terr i 5H3 fd 6H4 nd
4 45 aufid l, te It qui d 3fc alaf d aid H45, 394
a t W aga a dci chi 3ll4)vi sal l 31
HqP chi HMdd: h. R000/- do chi 3U I Hcn ।
qRaivi-l H
5.9000/-acCTDUTd)o5ferdH2HEondtEI aR4 9885
9% na 3 9%0 H45 (6% HcPT) Ife % 1 He add 08,08
oqaf a % W 330 Hce 9 9,3,449 ouar 8 Hnd 2"
tifaczu chi «P 36141 t I
51
3" W clv a a 96 HfAl 33 aud q7 9 o HfAid
H c33 c ferg Uo HTT3U SiH IAT usaT 5 1 •)
HH
39 do,
U chs Haivi 2 ft sd T3 %, wd : 9. a{ chi
HmH, 3. ss qru ch H{H, 5. f tiqat nffafar kg sueh
l qa <3 fl ci'll, «. aq HIHI- (kfsa, anf) te-T, 4. t
at,
. dr alaT, 0. 3-4
UI chi 3e!q*. 3lq doh sd T
zui H a afucbe? 3UT, 394 a a-4 >31 Rich alo ald 2" a
UseT 5 1 4s TR2 H5y dilM^llRcbdl HI It sid 5 aarfe
TRZicdl 3cH{ 3446 sld s I
*" a aciqm 9 o sohtdi H
? chi vIT Hal 1I ciushH cht
Htheid ch 5H ald d aicbl wIT Hchdl l te 34* a 3R co I
Hldid Tit 11
aeq" kg te ‘3 6 1
iff eft IiH seffd chizu c te W «i‘lis vild l :
as al uRdlei
aro Hfell anfc tldrid- ah nffafar kg
eft HH5 at tete a HCET3I cT Tated a--IT
9.2% 4 qee, ?. %u eft Ift d sclqrf, 3. arv ah at a
te ffde
3eqmf l
fazar old % l 5H f- HR 456 $$43 Eid 6 a Heac 655
atb’d 5q h 45 da chid 8 so ten Hee chi "U fci-T aify I
51. ade. ( gH.at.a1. H. a Uo . .at.) q5.a3.M..&RT
diafed zWzir chlusH ch Hs-Hdli$ 8 I
mR^hi ^t t-uifa a-l-i
990 tef & fachenu 4 HH-qu rfe ce ch te
3.3R3.A.qH. me a H q go UolR2e tert) chid 11
6
aw
uf
# 5H qRalHT ch E-uifd al c fed, cqtld chl
fraferat c se e ac eeT a - <HHT E’T ser ne cft
Hfsel
( Contd. from page 2)
intermediate factors :
#4-a ah chr cRT tqi it cR? Hchn 4 He7H if I
If SES affects maternal mortality it will do so through
5e ak9a a a- 4 zed g, {2-32" F8 H HEsfa
slHcfa eRT qfecbraf a HTH d fatgd WeR d HR chi
31a9ac t, act:, 3e WR a yfechref ch d4R ch‘=T afa l
$- a4R cR^ HH3, s al eRT a- TORT SFTT
He it a
5CT WT6u
H 5115-515 PT far eRT * Ha it soldid soh a
Hefguf 3 I
one of the following :
a)
Health behaviour - The things that people do or don’t
do for their health (health behaviour), is influenced by many
forces including many aspects of SES. Health behaviour
includes utilization of pre-natal care services, while
reproductive behaviour includes the age at which a woman
3U d a usshaT cfit Re al ch frd U.BR.Ht.Ud. eRT
pt Hchl Hiraraf 8 H q=c$ q-l-T inn, nifcal OiiqlDid
chi si a aJHa eRT alel- Jel- chi-T itPT, s-l st ThR
a H&H-*U H451 =RT tinfor fat 11 sHd sharfaf eRT Re al
eRT Hld-I PT Pt 3124- HHd it Hch’TT I
b) Health status - It is directly affected by SES. For example,
lack of money to buy food can result in anaemia. Health
behaviour also affects health status, and poor eating habits
too can cause anaemia. Poor health status may lead to some
complication which may cause a maternal death.
Helc PTP H, H2-30 H45 a 63 Uh 46c eRT, PTP ch HH614
PT cin H ar aldid ain 3 aqH?
gives birth, pregnancy order and birth-spacing.
6UN StHle sha RT
Hbel s 1 sH P3PP E Hdvfc HU-IT3, ATA!U ald-leigi, RI
Hq=t sHoifar, anf a faqui H Pop Pt PTP adells RT Hchd
c) Access to health services - Presence of facilities,
information about these, and financial and physical
accessibility. Availability of technology to prevent deaths from
common obstetric complications in the form of antibiotics,
caesareans, contraceptives and self-abortion procedures,
constitute an important aspect of the facilities available.
s l
U.B.f.q ar Hr!o HfeI enfach tld«E- H U$h
qia a aec eRT PTP CRT PPTP CRT PPTPT 11 su* frd PUP d,
3H3 fadzU P OTPTPPt P Hafud HTHTfch qRfefar aaid na
PT HIgchi? a del-IT H H&H-7UT HH% P a- HEsd faqar PP
d) Quality of care - Qualified personnel (physicians, nurses
and trained midwives).
e) Unknown factors - These also operate and exert their
influence.
31244- PT7PT ETT 1 d6152U PT PIT PT, 48 fafa PTTPT 3PP9RPT
If SES affects maternal mortality, an important
oTPT fPT tarad 3I yunef a J=fe PPP P PUP PT WWT H t-
programme option is to improve SES. If education is given,
unud En PT f^R, PTP H sobdn «ii PTT HH8 vin? E1TT I
it is likely to affect health status and health behaviour.
D
Similarly, better access to food may affect the nutrition and
hence the health status of women, which would lower the
risk of dying, in case there is a complication, and lower
•
(f-c 3lgdl •* "id sfdedc)
the risk of even developing a complication, provided there
is access to medical care.
Notes :
1. Food and Agricultural Organisation
2. United Nations
3. World Food Programme
FREE ABSTRACTING
The contents of this newsletter may be
abstracted without prior permission.
However,
we
would
appreciate
acknowledgement of the source and
copies of any abstractions
(To be Contd......)
□
Latest FRCH Publication
Doctor's Manual : Clinical and Managerial
Lalitha D’Souza, Mukund Uplekur, N. S. Deodhar and M.P. Dandare,
Vol l & II, 1996, FRCH.156 & 281.
Specifically aimed as a guide for a Medical Officer at the PHC,
this manual will help him perform his dual roles as doctor as
The views expressed in the articles are those of the
authors and not necessarily those of FRCH
7
elaborated in the first volume and as manger which has been
dealt with in the second volume.
FRCH NEWSLETTER, VOL X, NO.6. NOV.-DEC. 96
Index - FRCH Newsletter 1996
. ,
AT
January-February 1996
3) Local Belief Systems and Practices - Seema Deodhar and
Aarti Kelkar.
1) Personality Development Programme - Usha Kumari Kumbla
4) Swasthya Sevaonka Dhancha (Article in Hindi) - Dr. N.H. Antia
2) Environmental Education - Shriniwas Indapurkar
3) Jankari - Unnati Ki Paheli Sidi
Vaze
(Article in Hindi) - Vrunda
July-August 1996
1) Bam a co Initiative
4) New Arrivals in the FRCH Library
- Dr. S.N. Morankar
2) Drug Policies of India and Bangladesh
March-April 1996
1) Cooperative Financing for Health Care in Fural India - William
C. Hsiao and Priti Dave Sen
2) The Relation Between Universal Health Insurance and Cost
Control - Mark Goldberg, Theodore Marmor and Joseph White
3) The Coverage of Compulsory Health Insurance Abel-Smith
Brian
4) Health Insurance : Selected references from the FRCH library
5) Swasthya Ka Vittiya Sambandh (Article in Hindi) Dr. N.H. Antia
May-June 1996
:
A Comparison
3) Aushadhiyon Ki Aapurti Aur Unaka Istemal : Bahulyata kc
Madhya Garibi ( Article in Hindi ) - Dr. AnantPhadke
September-October 1996
1) Bamako Initiative - Dr. S.N. Morankar
2) Parinche Project in the Light of Bamako Initiative Dr. R.V. Banpel
3) Hospital
Waste Management
- Shriniwas Indapurkar
4) Sarvajanik Kshetra ( Article in Hindi
) - Dr. N.H. Antia
November-December 1996
1) Maternal and Child Health - Anuradha Gupte
1) Establishing Modern Medical Centres - Nikit Dravid and
Vaijayanti Aphale
2) The International Challenge of Tuberculosis - Sanjay Juvekar
2) Health Problems of Rural Women 3) Gramin Mahila Aarthik Swawalambam
Dr. R. V. Banpel.
BOOK-POST
(PRINTED MATTER)
Rodrigues
326 ,, 51 h Ma i n . 1 s t B1 oc k „
Ran q a l o r e 560 034
K A yr A t A kA
If undelivered, return to :
The Foundation for Research in Community Health
3&4 Trimiti B Apts., 85 Anand Park,
Aundh, Pune - 411 007
, ( 5 ! AMs g? Editor: VaijayantiAphale
1""
>
Assistance : Jayashree Puranik
"
5
/ Publisher .Foundation for Research in Community Healths
V
<
Mumbai/Pune
/
?
Seema Deodhar
(Article in Hindi) -
Position: 4060 (2 views)