COMMUNITY HEALTH - NGO Interventions
Gudakesh

The NGOs implementing health programmes challenge the basic aspects of the existing health service on the ground that it is (I) expensive (ii) curative, (iii) its focus is the urban area and (iv) most of the resources cater to a minority.

Hence NGOs’ focus is on transforming such a health delivery system, or providing an alternative model that (I) serves the rural areas (ii) is inexpensive (iii) is essentially preventive in nature and (iv) the resources cater to  a larger number of people.

A few NGOs into the alternative model may be mentioned:

• 
  1. The Comprehensive Rural Health Project, Jamkhed, Maharashtra, headed by Dr. R.S. Arole.  It receives considerable funding from Christian missionary organisations.  Dr. Arole’s work has won him the Magasaysay award.
  
  2. Dr. B.J. Cyaji’s group has launched the ‘Health to All’ scheme in two primary health centres.  Dr. Coyaji is director, KEM hospital in Pune.
  
  3. Some NGOs in Punjab, Tamil Nadu (Vellore) and Karnataka (Bangalore) are also involved in community health.
  
  4. The Foundation for Research in Community Health (FRCH), headed by Dr. Anthia is based in Bombay and has experimented successfully with community health models.

It may be instructive to examine the FRCH’s efforts.  Its essential input is the use of the Community Health Worker.  The CHWs take care of the basic health problems of the villagers.  They were used by FRCH first in Mandwa (Raigad district, Maharashtra), a few hours drive from Bombay.

The FRCH maintains that the single-purpose worker, the para-medical worker (like the auxiliary nurse midwife), who receives his  training over a couple of years and is a part of the medical system, cannot provide the kind of attention the villagers need.  As a consequence they turn to half-baked doctors and quacks.  This is an indication that the government health delivery system should be changed, through the promotion of CHWs.

FRCH has selected females, though the CHW can be a male.  The village women are in a better position to tackle the major health concerns which include propagating family planning, child nutrition, breast-feeding and immunization of children.

The CHW are given elementary training in preventing health: keeping the well water  protected, (de-contaminating potable water sources); tackling the mosquito problem, child and mother care, and so on.  The FRCH’s experience has been that simple village women picked up the basics quickly, including the ability to give injections.

A part of the FRCH effort has been to de-mystify medical care.  The FRCH stresses that the doctor is not essential; that the people have the capacity to look after the major part of their health problems.  Only the serious cases, like those requiring an operation, need to be referred to doctors.

Wherever the CHWs have been working, the birth rate has declined.  This is true of FRCH’s area of operation in Mandwa and its surrounding villages.  It maintains that the village women or CHWs are crucial for changing the health system from a delivery to a support system, where the people play a part and the service reaches the majority of the people in the rural areas.  Under the delivery system the government has not been able to provide health care to the villages.  FRCH studies suggest that the private health care system caters to 75 percent of the population; the public sector takes  care of the rest.

The share of the public sector is not likely to increase unless the people are made to participate in extending health care.  In this the CHWs play the crucial role.  They are in a position to provide round-the-clock service to the villagers, unlike government health workers.  They can also provide medical education gradually over a period of time to others, in the most appropriate manner.

FRCH maintains that training health workers through an intense course in some institution is not half as effective as talking of health issues at regular intervals over a period of time, gathered together in a school, a panchayat building (ghar) or under a tree, this being also an economical method.  Health education, to be a success, must be non-formal, a social function or people’s function.

The CHW is the central focus of FRCH’s ‘Health for All’ scheme.  It claims that the government has accepted the CHW scheme and appointed 2,50,000 CHW’s in the villages.

In fact, the government began promoting the idea of village level workers much before FRCH’s intervention.  To develop an integrated approach in the delivery of health care, as recommended by the Bhore Committee, the rural health services were initiated through the PHCs.  The outreach of the service, however, remain limited, and under-utilised.

The multi-purpose health-workers scheme was initiated in a phased manner in 1974.  It was hoped that this would ensure a more effective coverage of the population by the peripheral health workers and the supervisors.

But the multi-purpose health workers could not give full coverage with the desired frequency of visits to the targeted population.  Subsequently the Shrivastava Committee, which reviewed medical education, training and the utilisation of health serves, put forth an alternative approach.  It recommended selection and training of volunteers from the community to work as community health workers (CHWs) on a part-time basis.

The FRCH has introduced an alternative model of health care in an urban setting as well.  In 1980 FRCH adopted Laldonger, a large Chembur slum (Bombay suburb) of 35,000 to 40,000 population.  The strategy was to start with any work other than health care.  Thus FRCH initiated those projects that the residents wanted.

As the slum-dwellers were interested in education, the FRCH group introduced education, the FRCH group introduced education classes, teaching the three R’s and also began to train local people to become teachers.  After the group had been in the slum for six months, the residents who had begun to trust the FRCH group learnt that one of them, Amar Jessani, was a doctor.  He was asked to introduce medical education.  So he held classes on the basics of anatomy, physiology and health care problems.

The strategy of the FRCH group was to use the local organisations; the religious mandals and community gatherings to get across its ideas.

As is to be expected, once the group started to make headway, it began to face political pressure.  The religious mandal committees have their political affiliations, which provide them funds.  Thus whenever the group organised any activities, such as a sports function, it was besieged by mandal committee members asking the group to invite their political leaders to inaugurate it.

The fall-out of the FRCH group’s effort at Laldonger was as follow:

1. Once the slum community got organised, it continued with the education programmes.  Now a balwadi has been set up in the slum.

2. It was not enough, as the FRCH group discovered, to train locals (usually women) in health care without a referral service.  Without it a community health worker would be ineffective.  And the slum-dwellers would again turn to doctors who are easily accessible in any urban centre.

3. With regard to preventive aspects of medical work, much more work needs to be done in slums which are in a worse plight than villages with regard to (I) sanitation (ii) housing density (iii) population density.  And hence raising the slums health status is that much more difficult.

4. The common water-borne diseases in slums are typhoid (salmonella) and hepatitis.  The gastro-enteritis ailments are diarrhoea and dysentery.  TB is common.

Not all NGOs have confined themselves purely to the preventive aspect of health care.  The Arpana Trust in Karnal, Haryana, has gone in for curative  facilities as well, though its major focus is on preventive health care.  The hospital of the Trust had 50 beds in 1988.  On completion of the new building, 70 more beds were added.

Few NGOs have gone in for such a major curative facility.

The hospital (referral centre) is the only one that enables the Arpana Trust to secure an income.  Though most of the beds are non-paying, a handful are reserved for the relatively well-off, fetching Rs. 2 lakhs a year.

The focus of Arpana Trust is mother and child healthcare.  (This is true also of the Gandhigram Institute of Rural Health and Family Welfare Trust in Tamil Nadu, and to a lesser extent of Social Work and Research Centre - SWRC - Rajasthan).

What the CHW is for FRCH, the dai is for Arpana Trust.  But the CHWs of FCRH are the somewhat more qualified in so far as they are given more intensive training.

The preventive aspect of medical care is the Trust’s main concern.  This preventive campaign is organised from the 15 health centres located in as many villages.  Some programmes like immunisation are conducted in almost all the villages.

In the 15 villages, where the health centres are located, nearly all children under five years have been covered.  In the remaining villages the focus is  on covering those under the age of one.  In about 12 of them 60 to 80 percent have been immunised. 

The children are immunised against five diseases.  One set of injections cover polio, diphtheria,  tetanus, one dose of BCG for TB and another dose for measles.

There are 15 ante-natal care centres.  Women visit the centres of their own  volition.  This was not the case when the Trust workers began visiting the villages.  Workers  providing information and guidance to women on how to take care of themselves during pregnancy, often had the doors banged on their faces.  But now the response is more positive.

Apart from the 15 baby clinics (located at the health centres),  the Trust is running eight balwadis,  with an average  attendance of 45.  Particular  care is taken to identify the malnourished children so that they are given the requisite diet at the balwadi and are weighed and measured at regular intervals to ascertain their growth.

The family planning programme of the Arpana Trust meets with the strong  resistance of men.  Mrs. Ekka, the ANM (auxiliary nurse midwife)  with the Trust, says that in Orissa from where she comes the dowry systems is not so deep-rooted; daughters are not treated as a burden.  In Haryana whenever she has delivered a daughter,  Mrs. Ekka says she has seen the mother weep.  The average dowry is Rs. 30,000 to Rs. 45,000; the better-off give as much as Rs. 100,000.

Health camps are regularly  organised ( a common feature of many NGOs, such as SWRC).  The two types of camps are (i) medical camps and (ii) eye camps.  In the medical camps  the basic health problems are taken up.   In the eye camps, common eye complaints are addressed and operations performed for cataract, glaucoma and inter-outer lens implants.

In conclusion, it may be said that in its areas of operation the voluntary sector has been able to develop an alternative  model of health care that is in essence preventive in nature, cheaper than the existing model and caters to the marginalised sections of the population in the countryside.

Back to Contents