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5
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One could go even further as does Mackay, and question the extent to which primary health care, although needed, is in fact wanted by the populace.
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6
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84913810544
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Editorial
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This introduces the issue of lay felt needs and evaluation of existing services.
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(1981)
J. trop. Med. Hyg.
, vol.84
, pp. 93
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Mackay1
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7
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84913795163
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As pointed out by Sussman, the question for development policy is not always “what is the best way of doing community development, but what is the most politically and bureaucratically feasible way to do community development?” For India, the case of the Etawah project is instructive. A ‘go slow’ philosophy of flexibility and responsiveness to local needs ran counter to the political needs of the Indian government in 1950–1960 for rapid expansion and broad visibility. “From this political need can be traced most of the deficiencies of later community development efforts”.
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13
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84913763507
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Reflections on rural development
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Ghorpade M.V. Finance Minister of Karnataka State (1977) quoted in, 12 May
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(1979)
Mainstream
, pp. 11
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Srinivas1
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16
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84913750788
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Anthropology, government and development planning in India
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D. Pitt, Mouton, The Hague, Just as anthropologists have tended to study hill tribes more than mainstream society, a greater account of research has been conducted on ancient medical literature than on contemporary health culture. See
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(1976)
Development from Below: Anthropologists and Development Situations
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Mathur1
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18
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84913767408
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Praeger, New York, See also, L. McPherson Workshop Report on the Role of Anthropology in the Agency for International Development 1978, New York, On a slightly different note, Cernea discusses how indigenous anthropologists are often subject to pressures to defend the activities of domestic agencies
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(1979)
The Cultural Appraisal of Development Projects
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Cochrane1
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23
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84925932345
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Anthropological views of community and community development
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(1981)
Hum. Org.
, vol.40
, pp. 4
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Schwartz1
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25
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84913772636
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As described in the development and education literature, participatory research is conceived as an integrated process of investigation, education and action. My own perspective on participatory research links it to convergence theory in communication.
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26
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0002210063
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The convergence model of communication No. 18
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See, East-West Center, Honolulu, In terms of community diagnosis objectives, I concur with three participatory research objectives noted by Tandon: (a) To challenge the expert knowledge being used by planners and decision makers, revealing both the incompleteness of assumptions and inadequacy of knowledge. (b) To foster an alliance between professional researchers and lay representatives according them the opportunity to contribute to the process and direction of enquiry. (c) To translate popular knowledge into a form that planners and decision-makers understand and expert knowledge into a form the lay population can understand, making for better dialogue.
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(1979)
Papers of the East-West Communication Institute
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Kincaid1
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27
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0040780921
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Participatory research in the empowerment of people
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(1981)
Convergence
, vol.16
, Issue.3
, pp. 20
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Tandon1
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28
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84913764912
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The project was also structured in accord with an ideal community diagnosis team model conceived to fit into the existing rural development infrastructure, require few salaried specialists and be economically feasible. Administratively, local community diagnosis teams would fall under the jurisdiction of District Block Development Offices. According to the model, a state level (senior) community diagnosis team facilitator would be assigned to each district for 12–18 months to initiate community diagnosis team organization and leadership training in one-two development blocks. The senior team facilitator would organize a model community diagnosis team within the district and carry out a data base exercise serving as an opportunity for training regional community diagnosis team facilitators. Each community diagnosis experience would contribute to the development and generation of other community diagnosis team experiences by providing an opportunity for [[Truncated]]
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31
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84913769670
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The system used by the Population Center (Bangalore) to rank districts by health status was based on the analysis of an aggregate of basic health indicators (infant death, crude death rate, medical institution and literacy). The use of indicators such as infant death as opposed to infant mortality rates is questionable as is the validity of statistics employed in the formula. Population Center, District Health Status of Karnataka State, Population Center Newsletter, Bangalore, September 1978.
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32
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84913755265
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“One must be aware of the social landscape nefore determining sampling units:...samples must be based on an understanding of the representativeness of the data to be employed...informants should be representative of the social milieu...”
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34
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84913810852
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The towns chosen for study each had a Hospital or primary health center, a chemist shop, and at least two private practitioners from each major therapy system (allopathic, indigenous and eclectic medicine). The roadside villages had easy access to formal medical aid, while ‘remote’ villages chosen were not easily accessible to government health facilities and had no qualified practitioners within 3 miles dispensing allopathic medicine. Also chosen for a community diagnosis microstudy was a primary health center located in an interior South Kanara village accessible by road. In order to select representative settlements for sampling, the general distribution of health resources was ascertained by making a crude spot map of all available practitioners (traditional, eclectic and cosmopolitan). This endeavour was undertaken with the assistance of health center fieldworkers, local chemists, herb merchants, and local practitioners.
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35
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84913796087
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Patterns of curative resort and their significance for health planning in South Asia
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See
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(1978)
Med. Anthrop.
, vol.12
, pp. 2
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Nichter1
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36
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84913739386
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In North Kanara, individual caste hamlets formed closeknit social networks. Individual castes were therefore chosen as a sample variable. In South Kanara, caste networks were loosely organized. Communication networks were multicaste within broad caste ranges. For this reason, caste ranges (Harijans, Shudras, Brahmins, Muslims, Christians) were chosen as a sample variable.
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37
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This manner of addressing questions accords with that suggested by Cochrane: “Because those who administer questionnaires will inevitably be associated with officialdom, questions asking (villagers) to say what they learned (think), or did not learn, from extension agents are unwise. It is better to say “some (villagers) think this, some think that, what do you think?”
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40
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84913780679
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Research on the use of cultural rhetorical styles in enhancing health education is not discussed in this paper but may be found in Nichter M. and Nichter M. Nutrition education by appropriate analogy. In Innovative Approaches to Health Education: Case Studies (Edited by Israel R.). Education Development Center, Newton, MA, In press.
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43
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84913763776
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In 1978, there were 5400 primary health centers (one per development block) and 38,115 subcenters (approximately 7 per health center) Plans have been drawn up to double the number of primary health centers to two per block in keeping with the original suggestion of the Bhore Committee (1946). As noted in Banerji, implementation of this plan will require an expenditure of 45% of the government's health budget in the coming 5 year plan.
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45
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84913792866
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This finding is not unique.
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46
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84913755295
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Invisible hand and iron fist: the South Indian health bazaar
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For example, Nagpaul D., University of California, Berkeley, found that 90% of attendance at a primary health center came from a 5 km radius, 40% of cases coming from the village itself.
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(1981)
Report to the Professional Studies Program
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Kinosian1
Kinosian2
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49
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0019088345
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The layperson's perception of medicine as perspective into the utilization of multiple therapy systems in the Indian context
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(1980)
Soc. Sci. Med.
, vol.15 B
, pp. 225
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Nichter1
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50
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0020974930
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Paying for what ails you: sociocultural issues influencing the ways and means of therapy payment in South India
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(1983)
Soc. Sci. Med.
, vol.17
, pp. 957
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Nichter1
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51
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84913754020
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Basic Health Workers and Vaccinators became Male MPHWs and ANMs became female MPHWs. Sanitary Inspectors and Malaria Inspectors and Lady Health Visitors became Health Assistants.
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52
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84913753043
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The language of illness was very much a regional phenomenon in the areas of South India studied. Primary health center staff who spoke the same language as the rural population did not always understand local diagnostic categories or illness references. In fact, misunderstanding was common. A real need exists for regional illness guides.
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53
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84913786019
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Taylor notes “When will motivated Indian doctors [make] explanations to their patients...the experience has tended to be discouraging....It is not a matter of using the right words or village expressions. The gap is basically in conceptualization of what disease and health are.
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55
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84913755295
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Invisible hand and iron fist: the South Indian health bazaar
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As observed by, University of California, Berkeley, “The imposition of the individual target system has functioned to create conflicts within the PHC— frequently adding to the administrative difficulties. This manifests itself as pressures to falsify records and as non-cooperation with other staff, in order to steal an acceptor”. Competition for family planning splits the alliance of staff (e.g. ANMs and Lady Health Supervisors) covering the same population. Targets set for family planning and malaria control have also been found to result in non-performance of other duties by MPHWs, who essentially serve as uni-purpose workers under such conditions.
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(1981)
Report to the Professional Studies Program
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Kinosian1
Kinosian2
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57
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84913794319
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Nichter M. and Nichter M. The ethnophysiology and folk dietetics of pregnancy in South India. Hum. Org. In press.
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58
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84913741682
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The geographic positioning of a primary health center within a development block is often illogical in respect to the area covered and the availability of all season roads. Primary health centers were placed in villages/towns which offered contributions toward construction. For this reason, in some areas, building of a second primary health center in a development block may be prudent.
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60
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A useful critical analysis of the primary health center system which discusses family as opposed to community involvement in health programs is found in
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62
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84913799150
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Community involvement in development has been discussed and explored since the Etawah project in the early 1950s. See Ref. [7].
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64
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Community health worker: some aspects of the experience at the national level
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As noted by, primary health center medical officers often take on the responsibility of choosing CHWs from a list of candidates submitted from the community, Names of CHW candidates were elicited in South Kanara by primary health center staff and Panchayat leaders without the larger community's knowledge of the program.
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(1980)
Med. Friends Circ. Bull.
, vol.51
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Maru1
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65
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Community health worker: some aspects of the experience at the national level
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in a study of the opinions of primary health center staff towards formal control of CHW notes: The expressed desire for control was inversely related to the level of bureaucracy, The desire for formal control was the strongest among the lowest level field workers who interact with the CHWs on a regular basis. It decreased as we moved up to the district and state levels. Our study of PHC-CHW interface revealed that a large majority of PHC staff favored PHC controls over both the selection and the day to day activities of CHWs. Examples of views expressed by PHC field- staff are revealing. ‘Control is a must because people are dishonest; there is no love without fear, without our supervisors they will not comply with our demands as many of them are leader-type’. These views show how the authoritative culture of the bureaucracy continues to resist any new innovation which undermines its power to command and punish.
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(1980)
Med. Friends Circ. Bull.
, vol.51
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Maru1
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70
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84913754049
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Medical officers at a South Kanara primary health center located in a fairly interior village, a North Kanara primary health center located 4km outside a town and a North Kanara town Taluk Hospital (TH) were asked to rank outpatients on the basis of severity for a period of two weeks while a community diagnosis team member recorded observations. At all facilities studied, patients with acute ailments accounted for between 10–13% of the cases seen, chronic cases from 23% (primary health center) to 40% (TH) and mild cases from 47% (TH) to 67% (primary health center). Primary health center doctors concurred that mild cases could be handled by a trained paraprofessional.
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71
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84913767588
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When I speak of field training I have in mind here some form of field apprenticeship (see Ref. [17]) and not a brief course at a PHC accompanied by a ‘how to do community diagnosis guide.’ Support by a professional social science network would conceivably include periodic field visits, short courses and opportunities for social scientists and paraprofessionals from different areas to meet and consult each other. Professional social scientists would be required for field training and to maintain a support network. This would generate new forms of employment for professional social scientists involved in development work.
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72
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In addition to operational problems are problems associated with community research being perceived as a threat to vested interest groups and individuals. Heggenhougen (in this volume) has addressed this issue in a discussion of the degree to which development efforts are actually allowed to take place within sociopolitical contexts. An equally relevant issue is raised by Madan (1982). Madan acknowledges the rising number of non-Western anthropologists from developing countries who feel that they cannot remain content with the description of their own people's lives without turning to the moral issue of improving the lives of the poor and oppressed. He raises the issue that as indigenous anthropology takes up the ethics of development, it need beware of becoming ‘incorporated into the state’. In terms of the possible benefits for non-Western anthropology, I would suggest that community research teams may play a part in developing what has been [[Truncated]]
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76
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84913772205
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As Habicht and Berman have noted: The design of effective services will benefit from an understanding of how social factors affect the types of services provided, the distribution of services, the potential for secondary ‘spread’ effects in village society, and the development of representative local institutions that can foster future activity.
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81
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0019775683
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The creation of medical knowledge: some problems in interpretation
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(1981)
Soc. Sci. Med.
, vol.15 B
, pp. 379
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Young1
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82
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Several reports have suggested the need for a mid-level health workers role to ‘connect’ the health center with the community. The role is that of a change agent who helps villagers mobilize for primary care activities, choose CHWs and supervise their activities. I would suggest that this liaison role would be considerably more effective if instituted in conjunction with community diagnosis teams. It would be naive to imagine that one mid-level worker could effectively establish rapport—let alone mobilize villagers in a primary health center zone.
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83
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The emerging role of health in development
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On the need for a mid-level worker see, R.A. Smith, University Press of Hawaii, Honolulu
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(1978)
Manpower and Primary Care
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Smith1
Powell2
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84
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84913775206
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Health communication with rural audiences
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(1980)
Communicator
, vol.15
, pp. 1
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Coyagi1
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87
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84913775262
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See also Nichter M. and Nichter M. Education by appropriate analogy: new emphasis to an old approach to health education. In Case Studies in Innovative Approaches to Health Education (Edited by Israel R.). Development Center, Newton, MA. In press.
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