PRIMARY HEALTH CARE AS A SOCIAL MOVEMENT
By WILLIAM STANLEY
This paper is the outcome of our experience and insights gained while working among the poor. I request a Non Governmental Organisation called "Weaker Sections Integrated Development Agency," (WIDA). The center for Research on New International Economic Order being a research institute based in Madras, India have undertaken the above project with a view of exploring alternatives in the field of development, community health, people's organization and leadership.
The Project Programme is the result of a scientific study carried out extensively in the area of operation i.e., Koraput District, Orissa, India. At every level of planning of the Programme, people's participation was enlisted. This resulted in initiating the following programmes:
1. Development Education Among the Village People
To undertake a study in co-operation with the people on the present socio-economic, political and cultural system in the villages.
to identify the problems relating to development
to analyse the problems within the existing systems.
to create village cadres to act as catalyst in promoting a just order
to mobilized the like-minded people belonging to the exploited and under-privileged class into an organization.
to ensure and enroll people's participation at every stage of decision-making, planning and implementation.
to initiate a process of conversion of the habitual and dependent receiver-consumer to an independent producer as an individual or as a group through "Culturo- economic therapy".
to impart and continue education relating to awareness building and sensitizing people to their own situation.
2. Health and Nutrition Education among the Village People
to identify diseases and people's attitude towards sickness and modern medical practice.
to impart relevant health education to the community.
to identify and strengthen the indigenous medicine and its practice.
to extend training facilities to the local village dais (Traditional Birth Attendants), native doctors and create village health workers.
to undertake women's programme to consentise the women folk on women's problems, participation and decision making and formation of women's groups.
to make the people identify the fundamental problems of ill health through nutrition education.
to initiate preventive health care with an active support of curative and clinical programmes.
to undertake disease control programmes.
lastly to analyse the existing medical system.
3. Communication Programme
to strengthen the local folk media.
to disseminate relevant information to the poor.
to train young people on street theatre, drama, dialogue session, role play and puppetry.
Audio-visual systems are used to communicate to the people.
as majority of them are illiterates relevant charts and posters are prepared to communicate.
4. Skills Training Programme
to identify and strengthen skills in the villages like, pottery, weaving, blacksmithy, masonry, mat weaving and bamboo work.
5. Economic Programmes Aimed at Promoting
Individual and collective programmes are identified and implemented by the village people. The programmes are aimed to promote the standard of living of the majority. Issues relating to underdevelopment such as, poor wages, exploitation, of the money lenders, middle-men, landlords and local government servants at lower echelons are identified and implemented through organization - people's movements.
However, all the above programmes are intended to attempt in creating an awareness of the present system and provide alternatives in order to establish a new socio-economic and political order.
When India came under the fold of colonial imperialism, the local systems were relegated to lesser positions or thrown into the backyard of westernization. The indigenous system did not reach the urban centers and it was not found appropriate to the colonial rulers. Hence, the British had to import their medical system to cater to their troops, civilian expatriate and the local elite. As the indigenous system of administration, education, agriculture and medicine did not suit the colonial rule, they had to stabilize their own systems of administration, law, police military, industry and medicines thereby establishing our own Indian Systems at all levels.
People from the villages move into the new settlement of colony to serve the British. The medical system introduced by the British served only the urban population of both Indian and British origin. The minority of Indians who fled to the town accepted the new system of medical care. However, the rural people were practicing the indigenous medical system as a way of life. More than 100 years of rule by the British over India created a new socio-economic political and cultural environment. The System benefited only the west and the well to do among the Indians.
Immediately after independence, the Bhore committee in its recommendation provided a revolutionary alternative to the then health delivery system so that the Indian people will benefit by the new health care system in Independent India. Unfortunately, the political orientation of native leadership ignored the recommendations and continued to perpectuate the colonial tradition of urban-oriented, curative and a class character of the health services. Once again, it benefited the Indian rich and the majority was neglected.
The present health delivery system promoted by the Government is a mere adoption of the health care system that is being practiced in the west. In effect, India has virtually inherited the most modern medical system, with its own technological advancement, and is making it available to her people with a view to promoting health to all its citizens.
The health care services are carried out by the trained doctors in the modern medical system in established hospitals in the urban centers, and extending the services to rural areas through primary health centers.
Consequently, there has been a tremendous progress in furthering the modernization process of the health care at the level of medical knowledge, man-power training, technology and sophisticated approach to medical services. As a result, we are bounded to the collaborated multinational pharmaceuticals companies within and abroad, import of capital-intensive technology, computerization, high cost infrastructure (industry, hospitals, colleges, etc.) money hungry health personnel, and in addition to all these, to serve as a drug testing field for the western scientific progress.
Health services as seen by the increases in the number of hospitals beds, doctor-patient ratio, population ratio, training of health personnel, construction of primary and mini health centers at the expense of the majority has become a routine.
The myth of the medical care system, which was said to be serving the majority, is very evident in the findings of many WHO reports. The report quotes that "80% of the people living in the rural area contribute 75% of the national production are able to receive only 25% of the health services. And 80% of our doctors and 90% of hospital beds serve only 20% of the population." This was the reality even during and after the colonial rule.
We also learn form another report of WHO that , "India is the largest donor of medical manpower in the world and has suffered an investment loss of US 144 million dollars as a result of large scale migration of Indian doctors abroad." Even among those who stay back, very few doctors come forward to work in the rural areas and most of them prefer to stay in urban centers as facilities, benefits and incomes are guaranteed in the elite urban sections. As a result, medical care has become highly sophisticated, personalized, curative and hospital oriented. Therefore, health has become a commercial commodity-doctor and health personnel as owners of health and the afflicted people as customers and hospitals as private limited companies. Health, health care and health delivery system in India as a whole has now become a private enterprise.
Even today, the majority of the population of the country does not have access to the most elementary health care services. This does not mean that the Government should extend the present medical care system in order to reach the poor living either in slums or in the villages but to design programme for a radical change of the structures.
Not taking into account the factors influencing ill health, such as, socio-economic and political structures, which are exploitative, the Government have launched programmes. Money has been invested enormously on health care programmes. But, 'health for all' has become a mirage to the poor. Most of the Government and Non-Governmental programmes do not intend to question the very structure that makes people poor and thus inaccessible to health services.
It is clear that the people of India, particularly the masses ought to be mobilized in order to promote people based health care system. The entire population some how has to be brought in the process of decision making thus allowing health delivery as a "Social Movement". What is implied here is that, health should be controlled by the masses rather than a small privilaged class controlling it is in other systems of socio-economic and political sphere of life.
PRIMARY HEALTH CARE - AN ANALYSIS:
In our experience, we came to the realization that the existing health care, which is called 'Primary', deals only with Secondary problems of health. But the primary health care should deal with the primary problems of the primary communities. A Primary community is filled with the bonded labourers, landless labourers, marginal and small farmers, unemployed, the exploited and who are economically poor, socially weak, politically powerless and unorganized.
Primary problems are unequal distribution of land, resources and capital, private property ownership, low wages, irregular employment, appropriation of capital through land tenure, mortgage, money lending, high rate of interest, control of market, lack of basic literacy and the skill to analyse how they become or made poor, oppressive role of religion and the social system, diversification of the people as social groups of different religions, castes and lack of knowledge and information about the rights and privileges, lack of proper attitude towards their problems, the disparity of the rich and poor and the privileged and under privileged classes.
Secondary problems are only the manifestations of fundamental and primary problems as mentioned above. Hence, most of our primary health care, whether it is modern or traditional attempts only to treat the secondary problems such as food and nutrition, water and sanitation, disease control, mother and child care, formulation of essential durges, curative care, support of traditional medicine and health education in isolation to the root causes as earlier identified.
PRIMARY HEALTH CARE - A SOCIAL MOVEMENT:
It is imperative to rectify or restructure the above-mentioned primary problems of health at primary levels of life, then only primary health care can be achieved. This then would give strength and capacity to the whole community to collectively tackle their secondary problems such as infant mortality, morbidity, life expectancy and on the diseases itself.
Health is an essential indicator of the quality of life "physical", mental and social well being" for the standard of health is determined by the standard living.
In a context where the primary problem of society, namely, structural problems, which are highly exploitative, lopsided and oppressive, it is imperative for such communities to work for structural information as much as they would like to establish health as a right of every individual and the whole community.
It is therefore my conclusion that we in India ( as in other parts of Asia too) have to mobilize the interest and strength of our people towards establishing a health society keeping as a 'social movement'.