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1
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0024856330
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Vaccines for the Third World
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(1989)
Nature
, vol.342
, pp. 115
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Bloom1
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3
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84914978885
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There are, of course, also coverage problems in Northern countries. One of these concerns population groups which for religious reasons do not want their children to be vaccinated, which was the background to the 1992 polio epidemic in the Netherlands. Another regards undercoverage of specific social categories due to the fact that vaccination is mainly done in the private sector and not sufficiently covered by health insurance, like in the case of the urban poor in the U.S.A. [3a].
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4
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84914978884
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Freed G. L., Bordley W. C. and Defriese G. H. Childhood immunization programs: an analysis of policy issues. Milbank Q. 71, 65–96.
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6
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84914978883
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The research was, just like the vaccination and diarrhoeal diseases control programmes it studied, a top-down affair. A recommendation from a Delhi based official gave me access to the Director of medical services at state level. From there on I got access to lower levels, a step at a time. Lack of time was the main reason for not including the villagers themselves more actively in the study. What I did try, though, was to cover each administrative level in the public health bureaucracy. The state of Gujarat was chosen because of background familiarity due to my prior involvement in a drinking water supply scheme in the region. For more extensive data on vaccination in Gujarat see Ref. [13]. The study was supported by the Indo-Dutch Program on Alternatives in Development (IDPAD). Evidently, in other Indian states vaccination programs will have different characteristics, because the socio-cultural context is different. The results from the Gujarat study cannot, [[Truncated]]
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7
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0007924044
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To put immunization in its proper perspective, it must be mentioned that in India, as in other countries, such as Bangladesh and Indonesia, in case of family planning activities there is more pressure on target achievement and there are usually clear incentives for different levels of health care staff, e.g., University of California Press, Berkeley
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(1988)
The Politics of Health in India
, pp. 272
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Jeffery1
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13
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0022554598
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The Primary Health Care center as a social system: PHC, social status, and the issue of team-work in South Asia
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(1986)
Soc. Sci. Med.
, vol.23
, pp. 247
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Nichter1
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14
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84914978882
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With the exception of the polio vaccination which was done by the supervisor from the PHC, taking the vaccine along in a thermos when about 20 eligible children had been collected by the MPWs.
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15
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84914978881
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An additional point in regard to all work of MPWs is that they are under considerable stress: from having to reach targets, from having to carry out a multitude of tasks covering a rather large area with often bad communications, and due to a chronic shortage of MPWs. In the PHC areas I studied, these shortages were, respectively, 12, 20, 21, and 27% of the allotted number of posts.
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17
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84914978880
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Before the 1984/85 research I already twice visited one of the two study districts, Banaskantha. During these visits it already struck me that I had difficulty locating active village health workers (then named community health visitors). In regard to the difficult position of the MPWs and their relation to the village health workers see ref. [10a]. I still remember an interview with a MPW during an early visit to Banaskantha who told me “I do not know what I am. They call it a multipurpose worker, but what is it? I used to be a malaria worker, that is clear.” On the history and shaping of the indian public health care system see Ref. [6a]; on the community health visitor scheme see Ref. [14a].
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18
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0022264850
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Populism and health policy: the case of community health volunteers in India
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(1985)
Soc. Sci. Med.
, vol.20
, pp. 1
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Jobert1
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22
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84914978878
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Their typology is defined along two dimensions which coincide with those of group and grid as formulated by Douglas [18a, 18b]. She describes the group dimension as running between the extremes of a person increasingly exerting pressure that controls other people and a person increasingly being controlled by other people's pressure. The grid dimension covers the extent to which a person's life is regulated by rules and regulations.
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26
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84914978877
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In his interesting study [19] distinguishes four different cultural influences in the organizational culture prevailing in the Tamil Nadu agricultural extension services: dharmic, Gandhian, British colonial, community development. The organization of the vaccination program clearly shows elements of the strictly regulated British colonial administrative culture, while the multi-purpose worker concept has roots in the community development culture.
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27
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0342768311
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Discussion: we expect too much from community health workers
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(1984)
World Hlth Forum
, vol.5
, pp. 300
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Fendall1
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31
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84914978876
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Harijans (children of God) is the official name for people from Untouchable castes.
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32
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84914978875
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According to some, the HG can never act as a broker as the opposed interests of basic health services (BHS) and community based health care (CBHC) are hardly bridgeable [26a]. In my view such an analysis is premature, as it is insufficiently based on an analysis of the large variation of interface patterns between BHS and CBHC [23, 24, 26b].
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35
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84914978874
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This does not mean that I follow [27a, p. 717] when he described the Universal Immunization Programme in India as “... an awe-inspiring instance of the formation of a syndicate of medical scientists, bureaucrats and political leaders and their mentors from abroad, who invoked the emotional cause of the plight of the children in poor countries to build a closed, monolithic, ‘totalitarian’ programme”. I do share his fear, however, that vertical health programs which are strongly sponsored and pushed by foreign donors may jeopardize the quality and continuity of general health service delivery.
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37
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84914978873
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Heginbotham [19, p. 166] gives a highly relevant review of the responses of agricultural extension workers to the heavy pressures to achieve targets and comply with reporting rules. He shows convincingly the contra-productive implications of overemphasis on target achievement in the Indian context. The Hawthorne study remains, of course, the prime example of counterpoints to management pressure in the setting of a Western industrial organization. A good concise review of organizational social science research is [28a].
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40
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84914978872
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Past experiences of coercion in family planning and the integration of health care and family planning activities in the tasks of MPWs have negative implications for the effectiveness of immunization: “Village women are well aware of the significance to health workers of motivating sterilizations. As a result they are cautious of becoming indebted to these staff and vulnerable to moral pressure to be sterilized” [16a, p. 273].
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41
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84914978871
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Here we are confronted with a paradox: the more effective immunization is, the less it will be possible to refer to experiences of past epidemics when mobilizing people to immunize their children.
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42
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84914978870
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Visaria et al. [32a] who discuss the results of an action research program carried out in Gujarat in the mid 1980s, observed that their hope that mothers would themselves seek vaccination for their children from existing government provision after being motivated to do so by health workers from the research program was in vain. They hypothesize about the background of this failure: “Is the concept of preventive care difficult to grasp for people who are used primarily to using only curative care? While the Indian system of medicine has always placed a lot of emphasis on preventive and promotive care, modern preventive care through immunization is not a part of it. Perhaps parents do not like to take time off from work to take a healthy child for vaccination. Also, centuries of experience have perhaps induced a belief that diseases such as measles are an unavoidable part of the growing-up process of all children. Besides, health care available through [[Truncated]]
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44
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0342434771
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Female infanticide and child neglect in rural north India
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N. Scheper-Hughes, Reidel, Dordrecht
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(1987)
Child Survival
, pp. 95-113
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Miller1
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45
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84914978869
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In the central district where I conducted the study, there were two public health nurses doing the rounds of PHCs; in the peripheral district there were none. I was told by the Banaskantha DHO that in fact a public health nurse had been transferred to his district, but by pulling strings she had, as yet, prevented the actual posting.
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47
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84914978868
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I also came across a few cases, however, where a MPW did not agree to a transfer, supported by the community, which wrote a petition to the DHO.
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49
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84914978867
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This does not work automatically, as we can read in a small study in Northern Bangladesh: “There were many problems in the EPI, the most serious of them being the lack of proper supervision. There was virtually no record of those children who were left out or dropped out. With no supervision, the euphoria which was created during the early stage of the immunization programme through BRAC's involvement and the official's motivation disappeared. Workers were found demoralized. They remembered the initial period of EPI when all the officials were active. Now nobody showed any interest. They regretted BRAC's withdrawal from EPI in the Upazila” [38a].
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51
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84914978866
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The development of public health care delivery in the periphery of developing countries can be analyzed as a process of expansion and contraction, both tendencies often being recognizable at the same time. During a workshop at the Royal Tropical Institute in Amsterdam in November 1991 on “Implications of Structural Adjustment Policies for PHC in the Periphery: Four African Countries (Benin, Ghana. Mali, Zambia) Reconsidered” this process was described and discussed. Vaccination activities (EPI) were generally mentioned as one of the elements of thrust. A DMO from Ghana described, for instance, how in her district EPI services were expanded to “hitherto essentially neglected communities of the district”. Besides vaccinations, these areas did get very little public health care. The expansion of vaccination coverage was highly fluctuating. Some of the DMO's remarks on the implications of the process are of much importance. She pointed [[Truncated]]
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52
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84914978865
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Workshop on “Implications of Structural Adjustment Policies for PHC in the Periphery: Four African Countries (Benin, Ghana, Mali, Zambia) Considered”
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Version 1.1, PHC Programme, Royal Tropical Institute Amsterdam
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(1991)
Answers to the Questions of the Issues Paper
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53
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84914978864
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In an interesting paper Higginbotham and Connor discuss culture accommodation of primary health care. They define it as follows: “culture accommodation is the term applied to services that are permeable to community expectations and mobilize community involvement” [40a, p. 742]. Subsequently it is difficult to differentiate between the environment interfering with the services and intentional adjustment of services to elements in the environment. I, therefore, prefer to distinguish permeation and adjustment. Earlier I used the concept compliance instead of adjustment, but this may lead to confusion [13, 40b].
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55
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0024475417
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The continuity of vaccination programmes: reflections and a case from Gujarat, India
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(1989)
Soc. Sci. Med.
, vol.29
, pp. 1091
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Streefland1
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56
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84914978862
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This discussion of continuity from a program and policy perspective does, of course, lead to definitions which are different from views villagers may have. They may define it more in terms of chance, whose proportion will be related to past experiences.
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58
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84914978861
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It is important that the global level of health care provision and associated research is also changing. WHO of the 1970's is critically different from WHO in the 1990's and it is sometimes doubted whether the organization will be able to play a leading role in the future. This is the more important as such a role is apparently also aspired by another actor, The World Bank. Besides, the activities of another global actor, the Commission on Health Research for Development, have emphasized the significance of the national level 43a, 43b, 4].
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60
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0027165387
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WHO under stress: implications for health policy
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(1993)
Health Policy
, vol.24
, pp. 125
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Walt1
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61
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84914978860
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Frankel [23, p. 61] concludes: “It is only a minor exaggeration to say that CHW programmes have not failed: they have not been attempted!” On the basis of case-studies both he and Walt extensively discuss how to achieve improvement. As Walt states [34, p. 172]: “How to deal with this problem if inadequate supervision and support is perhaps the greatest challenge facing national CHW programmes.” She then continues that meeting this challenge requires changes in the whole health service, which could best be achieved when local health authorities are encouraged to find local solutions [24, p. 174].
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64
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The Bangladesh Rural Advancement Committee (BRAC) supported the government in getting its immunization program off the ground in one third of the country. Drawing on a large fund of experience in working with villagers and in managing large development programs, “BRAC's health workers and trainers served as consultants and trainers to the government's rural health managers through a management development program and with on-site help setting up rural immunization systems. BRAC trainers helped train the government's field-level workers in immunization techniques and in systems for setting up immunization days, rosters, and so on. BRAC's health workers also mobilized village communities to cooperate with the immunization drive and organized them to demand sustained immunization services after the first round of vaccinations was completed” [47a, pp. 62, 63].
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70
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84914978857
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Obviously, such drastic changes must be initiated in a pilot setting.
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71
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84914959079
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Developmental tasks and middle management roles in rural development
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D.C. Korten, F.B. Alfonso, Asian Institute of Management, Manila
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(1981)
Bureaucracy and the Poor
, pp. 76-86
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Satia1
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