First Contact Care: Flogging a Dead Horse?
Item
- Title
- First Contact Care: Flogging a Dead Horse?
- Creator
- Sham Ashtekar
- Date
- 2000
- extracted text
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MFC 2000 Meet Background Papers
7S2
First Contact Care: Flogging a Dead Horse?
Sham Ashtekar
I have a feeling I am writing on a subject that most health people have given up for various reasons- the CHW and First
Contact Care. Is there going to be anything like the CHW in the post 2000 health system of India? Or is something like
that necessary at all? 'Lip sympathy' on this issue abounds but of convictions or efforts there is little. Before getting into
the issue, it is necessary to distinguish FCC from the Primary Health Care which is the larger framework for health efforts
including health systems and hospitals, nutrition, drinking water, environment and all that goes into making health a
reality at national levels. FCC thus is a subset of the PHC framework, not an overlapping or substituting phrase. Our
group prefers the use of the phrase First Contact Care (FCC) for the village/community level comprehensive health care
facility through trained workers.
Can we do without FCC? I am one of the few adherents of a conviction that in a country that largely lives in its 5-lakh
villages and its doctors piling up in cities and towns, a well-trained health professional at village level is still relevant for
most health work. I am convinced that the health system of India is without its foundation if a village-based health
professional is missing. Sadly most States in India except MP and in some way Punjab have done little to save the dying
Dodo. I saw functioning FCC systems in China, Philippines, and Thailand with country specific variations. In China it is
already a third generation of barefoot doctors with three-year courses in institutes. Brazil introduced Community Health
Workers as late as 1995 despite being a 70% urbanized nation and far richer than India is. What is so special system of
India that we think that we can do without a reasonable FCC? Beset with problems. As a group working on PFIC tn
Maharashtra, we have been arguing about the need and possibility of FCC in the state for last four years with a definite
proposal for weaving a FCC network in the existing set of realities. Our experience has been that it is veiy difficult to
convince the government about FCC when it otherwise vows to provide primaiy health care every other day. There are
various conceptual and operational hurdles, which I am listing here:
Is FCC a state's responsibility? If yes, at least Maharashtra state is already doing it because the CHW is there on the
expenditure lists and to add to that we have now the Pada health worker (heath messenger). Tire ICDS was already there
in 1979. If you say that state is not responsible anymore, what about the legal problems involved in establishing FCC, the
connection on national health programs, and the linkages with public health system? The medical bodies are vehemently
opposed to the use of medicines in the hands of FCC workers- like what happened in Punjab. Even the private doctors
without much as a degree or training are opposed to it. A health minister who happens to be a doctor, is no less opposed
to FCC since he is not willing to 'hurt the medical system' and the 'sanctity of five year course'. Any non-doctor health
minister is simply afraid of stirring the beehive of vested interests. Congress did not like the idea and BJP can not hurt
middle class interests. The result is that no health minister is interested.
Come to health activists, the apathy continues. An eminent health activist told me that it is a bygone idea and 'it is twenty
years late'. May be this is an honest position, but we see every health project using the CFIW to do errands- in almost
every project that you speak of- RH, ARI, even income generation, microcredit, sustainable farming (sic) and so on. But
when it comes to FCC infrastructure, it is another matter, something bygone and out of fashion. I am particularly worried
by the fact that the RH agenda is being pushed despite the knowledge that there is simply no FCC system in most States
and many NGOs are lapping up the RH initiative no matter what is the state of the general FCC system or the lack of it.
Crores of Rupees were spent on an RH pilot project in Nasik district by the government without any impact on RH
ground realities. How can one think of such sensitive programs without someone to care for down there at the village!
It will be naive to believe that FCC is a simple matter, indeed formidable forces are arrayed against it. Politically it is not
an issue or popular demand. Doctors are generally against sharing the cake with anyone; politicians keep either a safe
distance or ensure interests of the private medical community. Bureaucrats are uneasy with the idea of such 'loose
participatory programs'. So it is nobody's baby any more.
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