Primary Health Care Cell of MFC: Report of the 3rd Meeting

Item

Title: Primary Health Care Cell of MFC: Report of the 3rd Meeting
Creator: medico friend circle
Date: 1992
extracted text: )12>
November 6, 1992

To:
Abhay Bang, Anant Phadke, Anil Desai, Ashok IBhargav,
Anil Patel, Anil Pilgaokar, Daxa Patel, La tabeni Desai,
Manisha Gupte, Narendra Gupta, Nimitta Bhatt, Rashmi
Kapadia, Ravi Na/ayan, Sham Ashtekar, Shridhar, Ulhas
Jajoo.

Dear friends,
Diwali Greetings !

Apologies for this very belated report of the discus
sions of the PHO Cell of mfc. I shall not give any
excuses for the delay but initially wanted to hand over
this personally at the last mfc meeting - which I did
to all those present. For the rest this got delayed
because on second reading I thought that the first
report was too long. So, this is an abridged version.
Sincerely,

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PRIMARY HEALTH CARE CELL OF. MFC;
REPORT OF THE 3RD MEETING

Venue: Sewa - Rural, Jhagadiya
Dates: 22nd and 23rd of June 1992
Present: Abhay Bang, Anant Phadke, Anil Desai, Anil Pilgaokar,
Lataben Desai,
Ashok Bhargava, Dhruv Mankad, Dileep Mavlankar,
Sham Ashtekar,
Manisha Gupte, Pankaj Shah, Rashmi Kapadia,
Shridhar and other friends from Sewa - Rural , U(kA.$
Before beginning the first session, some views were exchanged on
the issue of defining Primary Health Care from mfc’s perspective.
This was thought to be important- by some because

A) the Alma Ata definition was considered by them to be too broad
and encompassing issues of wider concern like nutrition
B) CHV - or as one participant felt better to call her a Village
Level Health Worker (VHW) in order to differentiate the idea from
the now rejected government’s CHV - is only a part of PHC
strategy and his/her scope differ under different conditions and
from different perspectives.
Finally it was agreed to shelve the discussion for the purpose of
this meeting and proceed to more concrete issues.
DAY

1 SESSION 1: EXPERIENCE OF VILLAGE LEVEL WORKERS
MANAGEMENT OF CHILDHOOD PNEUMONIA.BY AA'Chy ft A mC

TN

the study done by
Abhay Bang related the major findings of
SEARCH, Gadchiroli, which were that TBAs are the best persons to
reach out to and treat neonatal pneumonia. Also that the VHWs are
the most effective of the three in managing childhood pneumonias.
Discussion centered around the issue of relative mer i ts and
demerits of CHVs and TBAs and on the effects of successful
treatment of pneumonia on other causes of death.

DAY 1 SESSION 2 :
IN SEARCH OF APPROPRIATE LEADERSHIP AT VILLAGE
LEVEL BY ULHAS JAJOO.

Narrating the experience gained at Sevagram, Ulhas raised the
issue of people’s participation in selection of and control over
a VHW.
Fol lowing

were the main points discussed:

1. Since the poor were more involved with the struggle for their
existence, it was the middle farmer who had the time, opportunity
and also the need to take on a leadership role.
2. The curative role of the VHW was not perceived to be important
either because there was a hospital nearby for indoor care or
patients preferred private practitioners. This is also a new
emerging scenar io .- the peri-urban social set up having an easy
access to both private and government health facilities .

3. For outdoor treatment for minor or moderate, illnesses people
preferred going to a private practitioner even if the costs are
higher . This cannot be considered to be society’s comment on VHWs
potential when the the full potential of the VHWs is not uti1

It is wiser to ask as to what is more desirable,
if one
1ised.
towards
a
mors
rational
health
care
system.
wanted to progress

DAY 1, SESSION 3: LEGAL STATUS OF VHWS BY SHAM ASHTEKAR

Sham Ashtekar shared the various legal view points he had
summarised
ga thered f t om some legal expects. The main point are
below :
There is a plethora of statutes covering practice of medicine
i n India and any meaningful discussions on the legal status of
VHW can take place only after correlating the various Acts.
1.

three
2.
A medical practitioner of whatever kind is liable for
civil
kinds of legal action : Criminal (negligence etc.)
(compensation cases), action under the Acts under which they are
registered.
3.
The
question of practice
clarification on various issues:

wi thout

registration

begs

a)) What constitute medical practice ? Does only giving advice
constitute practice ?, Does free treatment and advice exempt one
from being called a medical practitioner ? What about registering
under one Act and practicing under another i.e. Cross-practice ?
b) What about practising as a part of a team? Who
legal liability of the members of the team ?

carries

the

What constitutes "acting under standing instructions "? Can an
ANN working in a remote area giving injection or a
mother
assisting a delivery be said to be acting under standing instruc
tions ?

While arguing for some sort of legal status to VHW, protection of
consumers from irrational practices needs to be ensured.

Following were the main points of discussion:
1 . Does heDshe
heOshs be seen as only a part of team not having the
right of practising outside of a team or as a para professional
governed by rules formed by its own body and having the right to
practice independently ?
View 1: Part of a team as there is a need for protection of
consumers from the potential of malpractice by practising VHWs.
11 was suggested tentatively that a VHW could be seen to be a
part of the village panchayat team.

View 2: As a para professional as the scope for VHWs is enhanced
if allowed to practice independant of a government or NGO’s control .
2. The norms for a VHW’s practice as well as the curriculum needs
to be
standardised
There, is a concrete proposal from the Population and Adul t
Education Cell of UGC situated in the Pune University. They have
requested Sham Ashtekar to identify centres where second year
college student can be trained as VHWs - Arogyamitras.

2

3. Some form of recognition similar to one accorded to the
gency Medical Technicians in USA should be asked for.

Erner-

This issue should be followed up with vigour and speed. Dileep
it with
<
Mavalankar and the Seva rural team volunteered to do
legal exports of CERC, Ahmedabad. Sham Ashtekar alsoi agreed to
They both agreed to report at the mf c
continue his efforts,
meeting in September 1992.

WITH

DAY 1, SESSION 4 : A.SEWA RURAL EXPERIENCE OF WORKING
ANGANWADI WORKER (AWW), CHV AND TBA
LEVELS OF VHWS

3

Pankaj Shah briefly recapitulated the history of collaboration
between SEWA Rural and the Govt. He recounted how in the early
Itipurpose workers (MMPWs) and the ANMs
having male multipurpose
days,
crea ted duplication of the roles. CHV’s role was only marginal
TBAs
and included the curative role for patients above 6 years.
were only called during delivery. Thus all of t.hern worked i n
isolation.

In 1984 when the Govt, abolished the CHV
integrating their roles. Thus, now,

Scheme,

SEWA

began

AWW gives curative treatment and looks after the children.
ANMs and TBAs look after Maternal and Neonatal care.
Male MPWs and ANMs both have a curative and supervisory role and
share responsibility of immunisation.
MMPW looks after control of communicable diseases and male
contraception.
FMPW takes care female contraception.

In their experience, CHV was not a very useful functionary,
But
they felt that this was also because their, curative role had
become more generalised . The paramedics and the AWW also gave
treatment for minor illnesses. However, the Sewa Rural experience
certainly highlighted the role of a VHW, in their case the TBA
and the AWW.
DAY 1, SESSION 5 : B. NIROG’S EXPERIENCE WITH
MATERIAL

HEALTH

EDUCATION

Ashok Bhargav reported on the activities of Nirog and narrated
the process through which the Health Education materials - posters and booklets
undergo before they are published for wider
dissemi nation.
He felt that since most of the HE material prepared so far by
eveni the voluntary agencies had been written by clinical doctors,
i t
■suffered from several weaknesses:
a.
a large amount of unnecessary detail.
b. Use of the language as it is written and not as it is
spoken
c. Shaded diagrams and photographs were not understood by the
people.
Thus the amount of information, the use of language and f inal1y
the type of visuals used, together made tire material uni nteresting and often incomprehensible to the people at whom the it was
di rec ted.

3

The specificity of Nirog’s material:
i. The large proportion of those to whom the HE materials address
are either illiterate or with primary level of school education.
ii. The information communicated through Nirog’s material is
brief and uses concrete ideas. Ability to comprehend abstract
ideas and concepts - that which cannot be experienced by the five
senses is a skill that comes at a fairly late stage in the proc
ess of learning. Only a VLHW who has had 8 years of formal school
education can learn abstraction, his view was however contested.

Ashok announced that Nirog will be organising a workshop on this
theme for those involved in using or developing HE materials,
some time before the end of this year.
DAY 2, SESSION 1:ROLE OF PHC CELL: IDENTIFYING GREY AREAS IN THE
SCOPE OF CHVS.

Anant briefly recounted the main points of his paper
the relevance and scope of CHVs.

arguing

on

1. This issue has to be discussed not only in reference to the
national situation but more so with the grass root situation.

a) In areas where a good hospital is available, a CHV may not
have a major role but for an activist group noL having a doctor
and wanting to do meaningful medical/health work, a well trained
CHV can provide a curative service for problems like malaria,
scabies.
b) Till
now health planners have considered only two areas
urban and rural but with a rapid urbanisation a third area is
emerging i.e. a peri-urban rural area around an urban a rea.
Medical practitioners have reached this area, It is necessary to
define the scope of VHW in such an area.

c) The role of CHV should be limited to provision of curative
service,
health education. To expect him/her to organise people
for health action is unrealistic.
d) There may be some compromise in quality of the curative iwork
of CHV but even then a well trained and supported CHV cani do
equally good work as compared to a conventional doctor.
2.
It was pointed out here that the following 5
cover CHV’s role :

A)
8)
C)
C>)
E)

poi n ts

broadly

providing treatment for minor and moderate illnesses
referring serious illnesses
participating in preventive and promotive health programmes
health education
preservation of traditional remedies

To this was added a sixth point F) maintaining record of vital events
However,
i t was proposed that the minimum role of CHV be laid
In addition to a minimum role there could be programme
down.
specific roles.

4

3. At tliis point several related, issues were raised:
1. What is the scope of a CHV in an inaccessible area ?
2. Wouldn’t the minimum role of CHV depend on the project?
3. How does the role of HW change with external development r
4. Howi do you determine such a minimum role?
5. Does the CHV only act as a 'screen’ or get upgraded as technol
ogy of diagnostics and treatment improves.
Here it was pointed out that an NGO may upgrade to the highest
possible level but. if system does not accept such a person .then
it is of no use. This also raises the issue of a patient’s
choice.
4.
It was argued that a CHV’s scope in an inaccessible area
problems when team support is not adequate :

has

1 ) Knowledge of system of medical care should be there in
to refer patients.
2) Supply of drugs
3) isolation
4) Legal problems.

order

5. Following points were made regarding the role of a CUV:

l.A CHV should be seen as a decision maker, an implementer and as
a person doing liaison.

2. A CHV ’ s role as Health educator , the level of 1i teracy r ethe legal position and the tasks expected to be perqu ired,
these are is demanding challenges for a CHV pro
formed,
all
gramme in a remote area. To meet the challenge and to use full
potential of a CHV, she should be part of team.
Fresh problems which CHVs should be trained to tackle
3.
be: ARI, AIDS and STD, Neonatal care, Asthma and so on.

cou 1 d

6. Some issues identified for further exploration include,

1 . What is the role of health education by CHV
2. Remuneration of a CHV
DAY 2, SESSION 2:R0LE OF PHC CELL: ISSUES FOR FUTURE MEETINGS

1 . Education role of CHV? kind of support required ?
2. Legal status
3. Developing curriculum for CHV
4 . Upgrading of VHW
Changing role
5. Developing a community approach to STD, Scabies,
ca re, alcohol.
6. Diff. members of PHC cell
causes of child deaths

neo-na tai

It was decided that at the next meeting of the PHC Cell at Wardha
on the 15th of September, papers will be presented by

1 . Abhay : Verbal Autopsy
2. Dileep Mavalankar and Sham Ashtekar : Follow
Status of CHV

The Meeting of the PHC Cell of mfc closed
Anilbhai and Lataben Desai and others at
excellent hospitality offered.
5

up

on

af te r thanking
Sewa-Ru ral for

Legal
Drs
the

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