4 THE PARTICIPATORY APPROACH IN THE NATIONAL HEALTH POLICY 2002
4.2. CASE STUDY: MAHARASHTRA
4.2.2. Analysis
4.2.2.3. Prerequisites for Successful Participation
MO Cooperation with Community (in %)
0 10 20 30 40 50 60 70 80 90 100
PRI Mahila Mandal SHG Schools NGOs Block
Development Committee
Other n = 102
MO Cooperation with Health Professionals (in %)
0 10 20 30 40 50 60 70 80 90 100
Anganwadi TBA Private
Practitioner
Traditional Healers
Community Health Committees
Ayurverdic System
Other n = 102
MO Ratings of Cooperation with Health Professionals (mean between 1 (very good) to 5 (bad))
1,6
2,1 2,4
3,1
2,2
2,7
1,8
0,0 0,5 1,0 1,5 2,0 2,5 3,0 3,5
Anganwadi TBA Private
Practitioner
Traditional Healers
Community Health Committees
Ayurverdic System
Other n = 102
Figure 4.44: MO Cooperation with Health Professionals in Pune and Raigarh
Figure 4.45: MO Ratings of Cooperation with Health Professionals in Pune and Raigarh
Figure 4.46: MO Cooperation with Community in Pune and Raigarh
MO Ratings of Cooperation with Community (mean between 1 (very good) to 5 (bad))
1,9 2,0 2,3
1,9 2,1 2,0
1,8
0,0 0,5 1,0 1,5 2,0 2,5 3,0
PRI Mahila Mandal SHG Schools NGOs Block
Development Committee
Other n = 102
MO Activities with the Community (in %)
0 20 40 60 80 100
meetings with community presentations for village visit families health education in schools ask community for feedback promote service in area assess health needs
n = 102
Figure 4.47: MO Ratings of Cooperation with Community in Pune and Raigarh
Figure 4.48: MO Activities with the Community in Pune and Raigarh
In the National Health Programme MOs predominantly receive help from the Anganwadi worker (97 %), followed by TBA (69 %). Since their help is part of their duty, it is not surprising that they are most important to the MOs. From the community help is rendered by Mahila Mandals (54 %), NGOs (40 %), PRIs (33 %) and SHG (23 %). Thus, for service delivery in the National Health Programmes community is still less important. Women groups are engaged more often than NGOs.
MO Opinions about NGOs (in %)
83
68
59
27
59
45
83
0 10 20 30 40 50 60 70 80 90 100
heard of NGO scheme
know NGO in own area
NGOs speak for community
NGOs money-minded
NGOs do good work in health
NGOs have medical expertise
NGOs to help you n = 99
Tasks for NGOs from MO Perspective (in %)
46 38
45 29 17 5
28
0 10 20 30 40 50 60
inform villagers about our services inform villagers about health
risk
inform about national programmes
give medication take over some of our
services control quality of services
do awareness raising
n = 99
The relationship with NGOs seems to be good. The majority of MOs knows the government NGO schemes (83 %) and most of them also know NGOs working in their area (68 %) (see Figure 4.49). The statements that NGOs speak out for the community and do good work in health and health-related sectors met the approval of the MOs.
Nearly all MOs think that NGOs could help them in their work (83 %). However, MOs believe to a lesser extent that NGOs do have medical expertise (45 %) and a quarter of them define NGOs as money-minded (27 %). MOs are interested in NGO cooperation and would like NGOs to help in delivering information about PHC health services and the national programmes to the community (46 % and 45 % respectively) (see Figure 4.50).
Direct service like giving medication to the villagers received less agreement (29 %) as did the taking over of some of the PHC services (17 %). Quality control of public health services through NGOs was the least favourite, it only received 5 % of positive replies.
Hence, MOs would like the help of NGOs in IEC activities but would not like to be controlled by them. Furthermore, they do not see NGOs to be fit to take up service delivery themselves.
Figure 4.49: MO Opinions about NGOs in Pune and Raigarh
Figure 4.50: Tasks for NGOs from MO Perspective in Pune and Raigarh
NGO Activities with the Community (in %)
0 10 20 30 40 50 60 70 80 90 100
workshops info leaflets presentations posters discussions theatre movies train people other n = 17
The activities MOs undertake and their perceptions of cooperation and NGOs point towards an interest in “top-down” participation (see Table 4.8). They undertake the activities as described in the health policy but do not expect community suggestions or active participation from below. Participation from community is again seen as compliance with medical treatment regimes and utilization of immunization or other services offered by the PHC. Public health programmes are not designed to involve “bottom-up” participation.
NGOs on the other hand need “bottom-up” cooperation. They cooperate with public health institutions and community. All interviewed NGOs cooperate with MOs and Private Practitioners (see Figure 4.41). Most of them also have contacts with MPWs, women groups and other NGOs (94 % each), followed by district officials and Anganwadi workers (88 %). PRIs (82 %), state officials and TBA (76 %) are also important partners as are community health committees (71 %). International organizations and traditional healers are on the last ranks, but 65 % of NGOs still cooperate with them. The ratings for the different cooperations vary between a mean of 1.3 for women groups and 2.5 for private practitioners (see Figure 4.42). Women groups were the only partner where cooperation was rated as “very good”. All other partners received “good”, except the private practitioners. Community health committees and international organizations are just ranked behind women groups (1.7 each), while MOs and MPW are behind (2.0 and 2.2 respectively). The cooperation mainly takes place in the form of information exchange and the joint organization of events. In their work with the community NGOs follow the
“bottom-up” approach, hence, workshops and discussions with the community are their priority (see Figure 4.51; 100 % each). Another important point is training of community members for health issues or other activities which 88 % of NGOs undertake. Through these trainings and workshops awareness about health issues is created and community members become empowered to participate. In the opinion of NGOs community cooperates with them as they mainly expect information and health gains. The indicator interest in participation for NGOs is high, chances of successful participation are therefore good as well (see Table 4.8).
Figure 4.51: NGO Activities with the Community in Pune and Raigarh
4.2.2.3.2. Communication and Information Transfer
Communication and Information Transfer within the Public Health System
Communication and information transfer within the public health system takes place through several channels. Similar to Himachal Pradesh monthly meetings at all hierarchical levels up to the district are an important setting for communication and information. MPWs and MOs have to write monthly reports including their achievements in the National Health Programmes and general performance indicators like utilization.
Individual reports are not discussed at the district level meetings as every meeting is attended by more than 50 MOs. The time for the meetings is limited. Discussions are thus confined to new government guidelines and general procedures. Information is handed down from the district officials to the MOs. Although only one meeting in Raigarh district could be observed, the “top-down” approach was also visible in Pune. The meeting was postponed from one day to another as it was convenient for the District Health Officer28. Since not all MOs have a telephone connection it is questionable in which way they were informed about the postponement. The meeting in Raigarh was very crowded. A small percentage of attending MOs was female. The room selected for the meeting was too small, so the meeting had to be shifted to another room which also did not have enough chairs. The organizational mismanagement of this meeting could point towards the lack of interest of the district officials. The observed power structure in both districts showed that district officials and especially the DHO perceive themselves and are perceived by their subordinates as positioned far above the lower levels like MO. The hierarchical gap is a hindrance for successful “bottom-up” communication (see Table 4.8).
The majority of MOs hold regular staff meetings every 3 weeks on average. All receive monthly reports from their subordinates and give feedback on those. MOs deliver monthly reports to their superiors and 96 % receive feedback on them. Furthermore, a high percentage of MOs (95 %) feels that their reports are used for district-level planning.
Superiors visit their facilities every 2 month on average. In fact, all ADHOs look after 3-4 blocks for intensive monitoring (ADHO 06.12.2003) and can therefore manage to visit the facilities. However, the maximum was 12 month between each visit, which shows that some places are more regularly visited than others. Although institutionalized communication channels like reports and meetings exist, information is only partly handed down or understood. Only 83 % of all MOs had heard of the government schemes to involve NGOs in RCH which was started in 2000. District officials subordinate to the DHO on the other hand were well-informed about the status of health care delivery at the PHC level and the existing problems. They receive this information through informal communication channels which are, thus, important for “bottom-up” communication and information transfer. Even though “bottom-up” communication is limited to informal channels and institutionalized reports, it nevertheless takes place. Still “bottom-up”
communication does not reach all levels. Statistics and reports do not reflect the real status of the public health system at the PHC level and below. Infrastructure like beds or
28 - The District Health Officer has the same administrative function in Maharashtra like the CMOH in Himachal Pradesh.
personnel does exist on paper, but is often not traceable during field visits. Furthermore, a large percentage of MOs (41 %) wishes to have better communication with their superiors (see Figure 4.37). The indicator for communication and information transfer, therefore, points towards a moderate chance for successful participation (see Table 4.8).
Communication and Information Transfer within NGOs
Communication within NGOs in Pune and Raigarh is good but differences among the organizations exist. Some larger NGOs such as K.E.M. Hospital Research Centre, BAIF Development Research Foundation or CEHAT have a board of trustees and other advisory groups like scientific advisory committee or social accountability group.
Communication is enhanced through these different groups. Since most of the interviewed NGOs are of considerable size, research groups and teams are a common form of work organization. Information flow within these research groups and to the director takes place in formal and informal ways. Reports about research projects are given to the director.
Regular meetings take place within the research group and also within the organization.
Information is further shared through newsletters or workshops. Smaller NGOs use the resources of the large NGOs for training of their employees and volunteers. The majority of interviewed NGO members (83 %) received training, mainly about health issues and project management. Communication among NGOs is thus also enhanced and further developed through the various NGO networks in Maharashtra. Information about health is mostly obtained from books or discussion with health professionals.
The same relationship between size of an organization and the extent of hierarchical levels within the organization like in Himachal Pradesh was also observed here. The director of the NGO represents the organization to the donors and government officials.
All interviewed directors except for one are male and either come from a medical background holding a doctoral degree or were involved in the freedom movement of India.
The seniority principle is evident in all interviewed NGOs. The longer people are working for their organization, the higher is their position within, provided that they have the required qualifications. The educational level of the interviewed NGO directors or project leaders was high, most of them hold a university degree. However, field worker of NGOs were mostly less educated, holding a school degree or below. The percentage of women was also considerably higher at the lower hierarchies. Although communication and information transfer within the NGO headquarters was observed to be good, field offices seemed to be less informed and involved in the NGOs proceedings. Since field workers are mostly recruited for specific projects, their part knowledge about the assigned project is sufficient for them to carry out their tasks. Linkages between field workers based at the project sides and the headquarter staff were not always strong. It was clearly visible that headquarter staff has more power and influence and is also better paid than the field workers. Hence, strong hierarchies also exist within NGOs but information is shared “top-down”, “bottom-up” and within the same hierarchy. The chance for successful participation is thus high (see Table 4.8).
Communication and Information Transfer between Public Health System and Community Although all MOs cooperate with the community, communication and information transfer between the public health system and the community is not always smooth.
Communication habits become traceable through health services offered including National Health Programmes, cooperation with community, complaint procedures and MOs attitude towards patients. Cooperation with community has been highlighted above, PRIs and schools received the best ratings. Contacts to the community are established through outpatient services, outreach activities as laid down in the government policies and through community health committee meetings.
Communication and information transfer between MOs and patients during outpatient services is limited due to the high patient load and the lack of privacy. The average number of patients per day in Pune and Raigarh is 46, ranging from 2.5 up to 150. Since outpatient treatment is confined to the mornings, the time per patient is very limited.
Although MOs said that they spent an average of 7 minutes with each patient and that they do explain the health problems to them in detail, it is not possible when looking at the simple mathematics. Firstly, seven minutes is a very short time considering that it includes history telling of the patient, examination and prescription. Secondly, if one multiplies the number of patients with the average time spent per patient, the opening times are exceeded by far29. Unfortunately, no outpatient service could be observed during the field visits as the doctor was either taking a break for the interview, no patients were there or the visit took place in the afternoon when no patients come for outpatient services.
Inpatients are rare and only admitted when family planning operations take place or in most severe cases like snake bite (see Picture 4.14).
Since most PHCs (55 %) do not have separate waiting rooms, patients usually crowd in the examination room and the adjoining corridor. Privacy in the doctor-to-patient contact does not exist, which is especially problematic in case of stigmatized diseases like Reproductive Tract Infections, Sexually Transmitted Diseases (STD), HIV/AIDS and Tuberculosis. Patients might be hesitant to tell about these health problems in front of fellow villagers.
Outreach activities include immunisation camps (93 %), Reproductive Child Health (RCH) services (83 %), health check-up camps (75 %) and eye camps (70 %). Other activities like meetings with community and health education in schools are also important (see above). MOs consider information about health to be most important after attitude of staff for villager’s decision about the use of the public health service. Therefore, all outreach activities include information delivery. However, messages are spread through posters and presentations. Discussions, which are found to be the most successful way for spreading information by NGOs, are not used by MOs. Posters and messages are kept simple, one example is the family planning slogan “We two, Our two” advertising for the two-children policy. Although the messages are easy enough to be understood, underlying problems like lack of pension schemes or poverty are not addressed.
Furthermore, the workload at outreach activities is quite high limiting interpersonal communication. At a three-day health check-up camp in Pen, Raigarh district, in February
29 - The maximum opening time calculated was 45 hours.
2004 nearly 10,000 people came to get treatment (NGO 14.02.2004). Although doctors from all surrounding PHCs tended to the villagers, the camp was nevertheless very crowded and people had to queue up for hours in the sun (see Picture 4.15). It was further observed that even though the participants wore traditional clothes indicating that they come from the villages, the clothing was still of good quality and very clean showing a higher social status. Only a very small percentage of participants were women. Hence, marginalized groups of society including the poor and women did not participate to the full extent. Better situated parts of the population benefited more from the health check-up camp. The treatment at the camp showed the same procedures as observed before.
People queued in the examination room and outside in the corridors up to the courtyards.
No privacy for individual patients existed. The time spent with each patient was about one minute, examination did not take place. Communication and information transfer between patients and the public health system hardly occurred.
Picture 4.14: Women in IPD after Family
Planning Operation, PHC Neral, Raigarh District
Picture 4.15: People Queuing for OPD at Health Mela in Pen, Raigarh District
Contents of Patients Complaints (in %)
0 10 20 30 40 50 60 70 80
attitude of staff lack of equipment
hygiene lack of medicine treatment given n = 90
Other interactions with community outside the doctor-patient relationship take place through community health committees. Advisory committee is another word for this committee. All MOs answered that they have an advisory committee. The committees were mainly composed of PRI members, MO and Block Development Committee members. Other members were less often mentioned. The committee was said to be useful and decisions were implemented in the most cases. Meetings take place every 4 months on average. However, in individual talks MOs revealed that these interactions are difficult since PRIs are only interested in economic activities and do not understand public health issues (MO 02.12.2003).
The attitude of MOs towards their patients also influences communication and information transfer. Patients voice dissatisfaction with services through complaints. The majority of MOs (85 %) receive patient’s complaints which are mainly verbal. The content of these complaints is mostly lack of medicine (77 %), followed by attitude of staff (49 %) and lack of equipment (49 %) (see Figure 4.52). Complaints about the treatment and the hygiene of the facility were less important. The MO side also felt that attitude of staff is most important to attract patients while free medicine only came fourth after information about health and hygiene of facility. Although many MOs receive complaints, only 37 % of those file a report, 57 % follow up the complaint, 64 % meet the complaining person and 64 % investigate if the complaint is true. The MOs who take further action after the complaint do so because they feel it is their duty, they want to satisfy the patient and improve their services. However, some also feel that it is not useful to follow up all complaints and that complaints are sometimes politically motivated. Communication in case of complaints can clearly be further improved.
Taking all facts together, it becomes obvious that communication and information transfer between public health system and community rather follows a “top-down” approach, is programme-related and is neither oriented on demand nor culturally sensitive. Thus, the chance for successful participation is moderate (see Table 4.8).
Figure 4.52:
Contents of Patient’s
Complaints in Pune and Raigarh
Communication and Information Transfer between NGOs and Community
All NGOs work with community. NGOs feel that community mainly cooperates with them as they expect better information. Hence, information about health is the main service offered to the community. Workshops, discussions, presentations, training and posters are important for NGO work with the community as it has already been pointed out above.
Furthermore, discussions are also the most important tool for community needs assessment which all NGOs undertake. Communication and information transfer between NGOs and community functions both ways “top-down” and “bottom-up”. The best rating for cooperation received women groups, followed by community health committees and international organizations. NGOs in Pune and Raigarh work through SHG, which are small homogenous women groups, sensitive issues can be addressed in these small settings. Trust between the members of the groups and between them and the NGO field person is established over the time through the joint saving initiative. Women feel more free to discuss their health problems there than in the PHC. Furthermore, one NGO even organizes a dialogue between the MOs and other public servants and the community.
They took up this programme to improve the understanding of the needs and limitations on both sides (NGO 19.11.2003). It has been already mentioned in the Himachal Pradesh assessment that NGOs rely on “bottom-up” communication. On the one hand they need community participation as they are required to involve the community by their funding agencies. On the other hand, they need volunteers from the community to implement their programmes. A mutual dependency is created. Nonetheless, the chance of successful community participation is good as communication and information channels between NGOs and community do exist and are used in both directions (see Table 4.8).
Communication and Information Transfer between Public Health System and NGOs The NGO ratings for cooperation with community groups are better than for public health personnel. However, they rank before private practitioners and traditional healers. All NGOs cooperate with MOs. The majority of MOs (72 %) also cooperate with NGOs (see Figure 4.46). Cooperation is rated as “good” from both sides (see Figure 4.42 and 4.47).
Furthermore, 40 % of MOs receive help from NGOs for the National Health Programmes.
MO’s mostly positive opinions about NGOs have already been indicated above.
Nevertheless, 27 % still think that NGOs are money-minded. The DHO also voiced his opinion that NGOs are controlled by funding agencies (DHO 09.02.2004). The cooperation between the public health system and NGOs in Pune and Raigarh is about ten years old (Ibid.), hence, distrust and prejudice are less common than in Himachal Pradesh, where the cooperation is younger.
The cooperation between NGOs and the public health system rather takes place on the local level which is shown by the NGOs’ affinity to cooperate with MOs, MPWs and Anganwadi workers rather than cooperating with district officials. The finding is also supported by the following statements of district officials.
• “NGOs work at the local level, not with us.” (ADHO 06.12.2003)
• “NGOs work at the PHC level. They have contact with MO not with DHO.” (DHO 09.02.2004)
Although cooperation exists more on a local level all NGOs except for one are convinced that cooperation with the public health system will be successful at the state or national level as well. All cooperations of NGOs with public health officials were rated as helpful to improve the public health system by the NGOs. Cooperation with MOs and district officials was even rated as very helpful. It is easier for NGOs to communicate with lower levels of the public health hierarchy. However, without the consent of higher levels successful participation is not possible. MOs partly rely on the help of NGOs. They receive donations in the form of infrastructure needed for National Health Programmes (tables, food).
Motivation of villagers by NGOs is also essential for MOs work. The help of NGOs is valued at the district and state level. The positive opinions of cooperation from both sides indicate that communication and information transfer works both ways. The chance of successful participation is thus high (see Table 4.8).
4.2.2.3.3. Responsiveness
The public health system in Pune and Raigarh can hardly respond to community needs.
Although funding and health targets are calculated according to population figures, health status does not play a role. High incidences in a particular disease do not translate into more funding from the central government. It has already been stated above that the results from the community needs assessment are used to evaluate the performance of PHCs but programmes are not changed. It takes a long time for programmes to adapt.
The lack of decision space for MOs limits their responsiveness, because they do neither have the means nor the permission to take action. In case of an epidemic they have to report to their superiors immediately. International funding also influences responsiveness. Maharashtra is among the states with the highest HIV/AIDS incidence.
For this reason, HIV/AIDS is labelled an epidemic here. Large funds are available for HIV/AIDS from international sources. It has become a priority issue in Maharashtra now.
Outbreaks of water-borne diseases and malaria occur regularly every year, even though preventing epidemics is a priority of the public health system. The response to these epidemics is slow. Although measures like fish tanks30 at the PHC are available for malaria prevention (see Picture 4.16), their use by the villagers still seems to be limited.
The lack of infrastructure and testing facilities at the PHCs prolong the specification of diseases. Officially all PHC should be able to test for malaria. Tests for tuberculosis or HIV/AIDS are only carried out at CHCs. However, malaria tests also hardly take place in the visited facilities because either the lab technician or the testing kit is not available.
Picture 4.17 shows a typical lab in the PHC. Responsiveness to the community needs is thus confined to the National Health Programmes, a moderate chance for successful participation (see Table 4.8).
NGOs in turn show a very open responsiveness to all community needs as the assessment of communication and information transfer between the two indicates (see above). All NGOs do a community needs assessment and receive their information through open discussion with community groups. Although NGOs are also sometimes
30- Small fish eat mosquito larvae. Villagers can obtain these fish free of charge from their PHC and put it into standing water bodies.