It would be clear from the foregoing sections that at the heart of what has gone wrong in our health care system has been to neglect the community as a rich potential resource and partner. Decades ago, in 1941, medical historian Henry Sigerist wrote, “The war against disease and for health cannot be fought by physicians alone. It is a people’s war in which the entire population must be mobilized permanently”. The national health policy statements from time to time play lip service to this concept, but except for faltering steps halfheartedly implemented such as the Community Health Guides Scheme of 1977, the kernel of our policies have remained top–down, urban–elite, hospital, doctors, drugs and cure–centered. Incidentally, the metaphor of war against disease is falling into disrepute, because wars are short–term campaigns and directed by a command system whereas public health measures must be sustainable and participatory.
Our approach has to shift fundamentally to placing the community in the center–stage, and building competencies and partnership within it for low–cost and affordable, people centered, preventive and curative health services. From an approach of health for people, we move to a ‘Demedicalised’ model of health by people, involving them at all stages of planning, implementation and evaluation. People are perceived not merely as the sources or victims of pathology, but as partners and resources or victims of pathology but as partners and resources. The community can be involved in assisting with logistics, funds and management of health services.
This volume will describe instances of how this can be done. It is important to recognize that despite all the imbalances and distortions in state programmes, it is very much within the scope of sensitive and creative district leaders to mobilize and harness such community partnerships. The pulse polio programme conducted countrywide in the winter of 1995–96 showed the benefits of community partnership in achieving real results in programme previously marred by mechanical and bureaucracy centered target orientation.
Need to develop partnerships
As part of this approach, the attempt should be to forge a wide range of partnership, to make the objective of health for all by the year 2000 A.D. a reality. It must be stressed that this is not to absolve the state in any way of its fundamental responsibility to provide the resources and wherewithal for the health of all its citizens. We require as much as a four–fold increase of the annual health budget in the public sector, and that government facilities and programmes must be made accountable to function effectively and responsively. However, these will remain pious hopes without public action, and such public action would necessarily entail adversarial advocacy but also partnership elements.
The most obvious potential partners are the NGOs. In some areas, such as jamkhed in maharashtra, sidhabari in himachal pradesh and BR hills in karnataka, NGOs have built vibrant models of alternate community base health care. They have also, been partners in training grassroots level workers, providing disability services and ensuring minimum needs. Yet at best, all NGOs together are not catering to more than five percent of the rural and urban poor.
In terms of scale, far greater potential lies in evolving partnership with Panchayati Raj institutions. This would require training of elected panchayat representatives, especially women and those belonging to lower castes, with the active assistance of NGOs. Significant work in this regard has been undertaken in states like West Bengal, Karnataka and Madhya Pradesh.
The traditional health care–givers are also valuable potential allies. In Jhabua, a Bheel district with some of the poorest social indicators in the country, district officers in recent years have been able to dramatically impact on IMR and child survival, most importantly by training local dais or traditional birth attendants. Without waiting for outside funding, the Collector undertook their training under TRYSEM, which enabled not only an attractive monthly stipend but also a free safe delivery kit at the end of the training. Since most dais were illiterate, training was undertaken imaginatively through pictures and oral methodologies.
Despite their commercial orientation, bridges may be built even with the private allopathic practitioners and the much maligned RMPs. Whereas strict vigilance has to be maintained to regulate medical and drug malpractices, the former can be persuaded to contribute to community health programmes such as health camps, whereas the latter can be trained in return for assurances for some public service.
In districts which have undertaken successful campaigns for total literacy, literacy activists are important potential allies for health education and mobilization.
One should imaginatively seek allies everywhere. It can even be the trader of a small rural grocery store agreeing to stock ORS packets, school teachers and students can again be important allies. Primary school teachers in some districts have been trained to screen their students for eye defects, early disabilities and leprosy, followed by referral of suspected cases for professional health assistance. In Jhabua, on a single day, all school children were asked to bring samples of salt used in their homes, and teachers tested these for iodine. This was repeated after a month, and the fall–out of health education on the importance of iodized salt was tremendous. The same district has also developed a health education curriculum for school students, who become ambassadors for health education in their family and the community.
The answers are relatively clear. What is needed is commitment of the state and resources, combined with our conviction as an article of faith of the paramount right of ordinary people to a healthy life, and of the enormous hidden potential of their becoming partners of the state to realize this fundamental human right of well being and ultimately life itself.