Primary Health Care

Full Title: *Primary Health Care and Community Participation*

_Address delivered to the WHO – UNICEF, Regional Meeting on Primary Health Care in New Delhi, November 21st – 26th 1977_

‘It must not be a process where some of us, with great scientific and technical knowledge want to sit down and plan and expect the community to passively participate. This is wrong. When most development organizations, including the WHO set the minimum human needs satisfaction targets for the year 2000 AD, for example, to give basic health services to every human being, do you think that most of the deprived communities in this world will accept it? Not only the WHO, all the world organizations, whose documents I have read, have set their tagets by the year 2000. A.D.’

You all may have heard the story of an old king who said ‘In my kingdom there are no thieves and there are no misers as well. If we apply this story to our times, we cannot think of any government in the world which could say ‘We are the Community.’ Similarly we cannot also find a community which could say ‘We are the Government’. In other words, still we have governments and communities within the same society which remain separated from each other. Most of you represent governments. I represent, may be a community. I know, we all would be very happy and satisfied if all of us can represent both governments and communities at the same time. Unfortunately, we are yet to see the dawn of that day. I have been asked to talk about community involvement and community participation. Therefore, whatever I say, it is totally from the point of view of the community and not from that of the government. I am solely responsible for whatever I say. I did not want to prepare a speech. If I did that I could have very successfully deceived all of you, so that I get another invitation from you to attend another seminar. I want to think aloud with you here and now. being a community worker, and being involved, 24 hours of the day, 365 days in the year, I will think aloud how I look at the theme that we discuss.

First let me congratulate the WHO and UNICEF for this very intensive study that had been undertaken in community organization, community involvement and community action with particular reference to Primary Health Care.

When a government cannot deliver the fullest services to its community to satisfy the community’s needs naturally community organizations at a non-governmental level spring up. I come from such an organization, the Sarvodaya Shramadana Movement in Sri Lanka.

Our organization always maintains four principal objectives:

Firstly, the total awakening of the personality of every human being, starting from oneself.

Secondly, awakening of the community; it may be the village community or it may be an urban community. In other words, considering that every human being belongs to a small community, the total awakening of that community.

Thirdly, these communities are organized in modern times as ‘Nations’, therefore, national awakening.

Fourthly, we can no longer talk in terms of individuals, communities or nations; we have to talk in terms of the world; therefore the world awakening.

These are the four aspects of total awakening.

For the human being to awaken himself there are certain basic human needs that have to be satisfied. With regard to these human needs, there must be a certain consensus of opinion among communities and governments. Therefore, in our work as village level workers, we always keep in mind ten basic requirements that we feel are essential to be satisfied if a human being’s personality is to be totally awakened. These are:

# A clean and beautiful environment.
# An adequate and pure supply of water.
# The minimum clothing needs.
# An adequate and balanced food supply.
# A place to live – housing.
# Basic health care services.
# An access road to their community and also a path-way to their homes and communication possibilities.
# Energy sources – to boil their water, to cook their food, to light their homes.
# A formal and an informal educational programme, which is not confined to a particular age group but which caters to the needs of the community as a whole.
# Lastly, they should have a cultural and spiritual environment in which those innermost needs of the human beings could be satisfied.

Within the context of these ten basic human needs, of course, come the primary health care programmes. When you think of these ten basic human needs, you cannot think of them in isolation. You have to think of them as one total process. Today, in the world when we talk of development, or anything as a matter of fact, we hear very much talk about people’s participation. Here also we talk about community participation, community involvement, community action, mobilization of community resources for effective primary health care work and so on. Why only talk of community’s involvement in something which is evolved by somebody else? Why not we talk of the governments and others getting involved and participating in what communities have thought about and developed also?
Now in my own country, in over 1000 places, especially over the last five years, we have evolved a system where pre-school children, needy school-going children, lactating and expectant mothers, sick and old people – these six categories of people – are being organized on their own to provide three essential services, namely, nutrition, health care and mental and social development services. This is being done in about 1000 places involving nearly 150,000 who are beneficiaries as well as participants. I say beneficiaries as well participants because they are not only recipients of certain services but they are also the promoters of those services.

No government service programmes, I know of, exist in my country that cater to this number of human beings in this type of organized and people-centred manner. In other words a non-governmental programme in Sri Lanka has succeeded in building up an effective children’s service programme. This is a programme of the people by the people for the people keeping the mother and the child at the centre. Here is a programme that has been evolved by people themselves in response to their felt needs. What a government should do, what the social development planners and administrators should do, is to identify these programmes and render them all support to do their work better without trying to control or manipulate them.

In an instance like this is it wrong to tell the planners ‘Look, here we have succeeded in building up a children’s service programme. Why don’t you build into this programme what you intend to do in this field? Participation and involvement must be a two-way process with mutual respect and equality in association.

It must not be a process where some of us with great scientific and technical knowledge want to sit down and plan and expect the community to passively participate. This is wrong. When most development organizations, including the WHO set the minimum human needs satisfaction target for the year 2000 AD, for example, to give basic health services to every human being, do you think that most of the deprived communities in this world will accept it? Not only the WHO all the world organizations, whose documents I have read have set their targets by the year 2000.
Last Thursday, in my own country, I attended a public meeting. Three young men came to me and said ….. Sir, on your return to Colombo, you must visit our village’. I said, ‘I cannot promise to come; but where is your village? They told me that their village was called Ampe, which I had to visit when I return home. I said, ‘when I come to your village, pass through your village, it would be mid-night’. They said, ‘It does not matter, from ten o’clock in the night onwards we will sleep near 48th mile-post till you come so that we could take you to our village’. I reached the village at eleven o‘clock. These people took me to the village and there were nearly 1200 men, women and children all seated on the ground in the open air. They were having a folk play until I arrived. It was never planned; it was planned only that evening. They told me that 15 years ago it was difficult for them to reach the bazaar through another village because they happened to belong to a socially lower caste. So, they decided to stab one of their own men and implicate another from the next village and thereby create public opinion against this injustice. So two of them in mid-night walked towards the main road and exactly near the home of the leader of that higher class community, took a knife, wrapped a piece of cloth around that knife and stabbed the other man who was his own friend, to involve somebody else to bring about public opinion. He never meant to kill him. It went half an inch deeper than what they expected. The victim died and this created public opinion. This was how they got the access from the village. They told me ‘we do not want to fight anybody; we are well organized to develop the village’.
After centuries of deprivation and suffering they have organised themselves for self-development. Can I tell the, ‘Please wait a little longer – till the year 2000 A.D All your problems will be solved’. This is impossible. While there is malnutrition among the vast majority of people in the world a minority of rich people have enough to feed the world. What do they do? They spend billions to produce armaments. They destroy their yields or underproduce food grains to keep a stable-price mechanism. While these injustices are going on in the world can we turn to the poor and say ‘wait till the year 2000?’ This is absolute nonsense.

I am not a political leader. I am not an administrator. I am not an academic but I am with the poorest of the poor all the time. Therefore, as a true representative of the poor, I would say that the time has come when not only the communities have to be involved in the development process but more so the establishments have to be involved with the poor because they too have to undergo terrific change if the poor are to truly benefit.

Can we organize community involvement and participation programmes into governmental and inter-governmental services so that they could meaningfullly fit in? If we agree on certain basic principles of development we can do this.
There must be a common language of development which is equally intelligible to the elite and poor alike. We must stand on common ground. We should not take for granted that communities, because they are poor, or because they are illiterate, are also ignorant. Sometimes the most enlightened people are the illiterate and under-trodden people are the illiterate and under-trodden people, because they have learnt through the university of life, the university of suffering. They have survived in spite of the fact that they have to walk eight to ten miles to get a bucket of water to drink. Therefore, it is very essential that on certain basic principles we should agree before we plan our programmes.

Development should be for the benefit of every human being. Development is not the mere production of goods and services and forgetting about the fact whether they have reached the people or not. Human beings should be the target of all development. The last in society should be our first concern. Development should start from below; not from top downwards. Development should start with what people have their knowledge and their resources. Every community is in a process of development and has reached a particular technological level peculiar to that community. We have to start from that level, unless we can have the magic of giving them the best overnight, which is impossible. Then get the total community to participate in this process of decision making.

As much as we are concerned about their health – they too are more concerned about their health. When they are told that every six hours 4000 people die of malnutrition in this world, they themselves can understand this in reference to their own community. Now if you take the ten basic human needs I outlined and break them down to about 400 parts with them, which we have done and put it before the community they are capable of recognizing those fundamental needs which can be satisfied by their own efforts. That is an education for the community. Without education, without an awakening process, no participation can come about.

Today in my own country ( I am sure this is the same in many other poor countries), there are a number of queues, people lining up, you can see. If you go to a co-operative store, you see people lining up to buy their rations. If you go to a member of Parliament’s house, there will be people lining up to get a chit to get jobs. You go to the health service or medical clinic, people will be queing up there too to get medicine. Can’t we turn these queues the other way. We can. And what is the principle of doing this? Make those very people for whom our services are meant not only the receivers but also the initiators of these service programmes. Then as I mentioned we, who belong to non-governmental or governmental organizations, do not have to waste most of our time trying to organize the community. The communities have the potential to organize themselves. Others have only to give the freedom and opportunities they need.

Government should essentially render other services which create the environment and supplement people’s efforts. Firstly the government should give them social justice under the law. Government can give the expertise wherever necessary. Government can divide its resources according to the needs of the people, government can create that psychological atmosphere where the people can feel free for self-development. Governments can bring them face to face with the highest developments in the fields of medicine or health or technology when they are of benefit to and appropriate for the people. Leave the governments to do those big things. Give the people the freedom to organize themselves to see to it that every pre-school child in the community gets those services of nutrition, health care and a good atmosphere leading to social and mental development.

In our countries we have in the age groups of 18 to 30 or 35 – many hundreds and thousands of young people who are unemployed – unemployed not only in the sense of getting no income but also not having any useful work to do, which is very frustrating. It would not cost the government very much to take in these young people and give them a training in basic essential health care for a period of three months or so. Being a non-governmental body we are training at one time about three hundred such people so that every three months we are able to start 300 new children’s services centres.

You may call her a primary health care worker or pre-school worker or a young sister doing children’s services in the village. There have been statistically proven improvements in the level of health of the groups they serve. There has been an improvement in the cohesive nature of the community they serve leading to self-development. There has been an all-round understanding that, after all it is self-reliance and co-operation on the part of the people that can bring about a change. I am emphasizing this aspect of people’s initiative and leadership very much because what we decide for them in international conferences is not put into concrete practice at that lowest level.

We have had many visitors from international organizations seeing our programme in action but hardly any development administrator from my own country has visited us. Why is this? People are ready to get involved, participate and work, as long as they know that the programme is an honest and genuine effort to bring about development. They are ready to co-operate. I have yet to come across a community that did not co-operate, but we – the educated, the elite are not ready.

I have been a community worker for over twenty five years. Some political leaders turn round to me and ask, ‘What are you doing? I am sure you are trying to do politics’. Some administrators, turn round and say ‘development is none of your business’. In other words either I have to turn to be a politician or find an administrative job else-where. In the same breath they say people should participate in development.

There should be a total awakening process not only on the part of the poor people but also on the part of the administrators and the leaders of our countries. This awakening cannot come about unless they all come down to the grassroots and work with the people. Over a period of time, the health administrators of our countries too should come down and serve as primary health care workers at the village level. Then only a psychological integration can come about. The WHO has accepted, as a principle, the involvement of the community in health care work and the importance of the primary health care services. I would ask you to make a survey of our own medical practitioners and find out how many of them agree to this view. Most of them think that the level of their professional excellence is brought down by people’s involvement. This mystified nature of the medical profession has to undergo a fundamental change. We need, like in China, the recognition of the need for and the value of bare-foot doctors. 85 per cent of our illnesses, you all have mentioned, can be prevented at the basic level. 85 per cent of our money should go there. But do we do it? When the political leadership asks from the health budget, 75 per cent to put up new hospitals, do you oppose it as a profession and say ‘Please do not do it, spend more money for the preventive services’. This is not done. Why? Because there is not enough experience and commitment among those who decide for our communities. Therefore there should be a concerted effort on your part to awaken our people, to get them into action, to give more knowledge, to train personnel from their own community and to send them back to the community. There also must be an educational process for the people who man these services at the top. Then only can we realise our objectives and the lofty ideal of the health of all.

I am talking as a man who has to face these problems everyday. That is why I am talking with a feeling of conviction. Coming to concrete action programmes that we can implement at village level, I would mention again that Primary Health Care should be a part of an integrated programme of development. A lot of money and time and energy must be spared to be spent to bring the knowledge right down to the grassroots, in a simple and intelligible way. I do not think this is happening very much compared to the volume of high technical papers that are being produced. Very simple manuals should be prepared to be used at that level. We need a lot like that on every subject.

Now let me briefly mention how a Sarvodaya programme begins in a village. Our first objective is to build a psycho-social infrastructure in the village. When a village wants to join this Movement, we say ‘all right let us organize a shramadana camp enabling us to do a labour intensive task while living together for three days’. By that what I mean is that the village community with those who come from outside, spend time living together, cooking together, eating together, discussing together, singing and dancing together and doing a community service project for two or three days according to a certain time table. To that camp we invite all the government personnel at the community level to participate as equals with the people. This is to break psychological barriers that exist. There are barriers of dependency and patronage – and barriers of superiority and inferiority complexes. All these have to be broken down because a psychological infrastructure has to be created not only among the members of the community but also among the people who serve the community.

While people live together like that for a period of time, they may contruct a series of latrines, wells, soakpits or tank bunds or a road to the village so that all share the joys of a beneficial physical achievement. But the most important outcome in the first stage is the opportunity the people get to think together, to plan together, to work together, and to feel that they have a great potential for self-development. This is community education in a true sense.
We next come to a stage of organizing a mothers’ group. Mothers’ group selects one or two willing girls between the ages of 18 and 30 based on criteria commonly set to be sent for a period of training to a Sarvodaya Development Education Institute. We have six large Institutes of this type and several smaller ones. Training is also a type of community living. There you do not see any marked difference between trainers and students. They all live together and share experiences as members of one large family. Our Regional Director Dr. Herat Gunaratne and several of you have seen these institutes. They learn theory through practice, so that within three months you can give them maximum practical knowledge. When those young people come back to the village, they not only take with them certain skills in the PHC field but they also take with them certain changed attitudes. They would not come back to the village as persons with certificates. We do not give certificates. Only after two or three years we give a certificate for exemplary, creative and innovative type of work.

It is not for certificates that these people come. We are not paying them any salary. They first learn the science of serving their people and receive the joy of living by learing the art of loving their fellow men. This service is known as a pre-employment voluntary service. We believe that the government will say one day – ‘Well, we pay 50 or 200 rupees per month to that village level worker because he or she has proved her worth in taking care of our children. Let all the 23,000 villages of our country have the services of such inspired and trained youth’.

The mothers’ groups in the villages have to be in general charge of the children while the pre-school girls are in training. The youth groups in the villages put up the required buildings with local material. Other elders in the community help in these activities. When the trained youths return to the village it becomes very easy for them to start the Day Care Centres for children below 3 years of age, pre-schools for those between 2 and 6 years of age, community kitchens for the needy, pre-natal and post-natal care for mothers and child welfare activities for children with help from the public health midwife, Immunization and Environmental Sanitation Programmes with the help of Public Health Inspectors, home gardening campaigns and other community services. They maintain health cards for children and establish working contacts with governmental medical and health care personnel.

This is how we have tried to bridge the gap between the available governmental services and the real needs of the people. However it is not always that we get the willing co-operation of the governmental extension services. Therefore we have obtained the services of a group of doctors, nurses and health persons as volunteers who make use of their leave to come and help our village health projects in such situations.

If the governmental services give official support to voluntary bodies to organize mothers, children and youth in this manner without trying to lay down the law for them the outcome will be tremendous. Instructing the local bodies to assist the up-keep of workers and provide the basic material, providing the medical and health personnel to help the programme, making available simple health education and primary health care manuals are some of the ways that the government can help these people’s efforts. Then the governmental resources would have been utilized much more effectively than it happens now.

Let me speak a few words about research. This is another area that needs demystification. We also do research at the village level. Not high powered research but very simple research useful to the people and the results of which become common knowledge to all people of the community.

Let me give an example. Everybody needs water for their personal use. We do research to find out how much hygienic water each member of the family needs a day and the total number of gallons of water the whole family needs. Similarly how much all families in the village need. In actual fact how much of water is available in the existing wells and how many more new wells have to be dug to give the village an adequate and a clean supply of water. A group of village youth with a simple training becomes the initiators of the research programme that is carried out with the villagers themselves. Next they become the well-diggers all-together once the research is over.
Now to build up these wells, they have to find money for cement, bricks etc. Either the government has to have a system whether through local bodies or through relevant ministries, when such a programme is going on, to give the material that is necessary or non-governmental organization has to support them. This also means that the village needs a group of young men and women who are skilled in certain technologies of well construction, house construction, toilet construction, etc. So this leads to a Movement of regeneration of the quality of village life. So I would plead with you to look on this as total process one leading to another.

The village communities have to get committed to bring about better health as an integral part of total development. Those who are more fortunate than others to be in a position of making decisions that affect the people also have to make a serious commitment. This is much more difficult than awakening the village communities because vested interests are more in decision-making groups unlike in regard to the village people. So, if you face facts, we have to bring about commitments either by persuasion or by compulsion, if the governments really mean what they say. We have to get both these groups awakened as to the danger that we all are facing in the years to come and pull their weight together to avert it and promote good health for all.

To bring about a more healthy life for our communities we have to bring about changes in three related areas. Firstly, we have to bring about psychological changes, I have been talking about. Secondly, we have to bring about changes in methodologies and techniques where we try out not only the methods and techniques coming from top to bottom, but also think of those that have been evolved from bottom up. The latter could be linked to the national services. Thirdly, structural changes This has to be elaborated upon a little.

To stress on the importance of changing structures permit me to give an illustration of a village experience. There was a high incidence of infective hepatitis that was prevailing in one of our villages where a primary health care worker was functioning. She found that at one time as many as twelve families had this desease. When she explored into the root of it she found that the source of water – which was running stream through the village – was being polluted by a newly started factory. Those who imposed the factory on the village did not look into how their actions would affect the health of the villagers. Are we turning a blind eye to this type of situation and only try to repair the damage done?

We have to turn our attention to structural incongruencies and injustices that are imposed on our peoples. If a poor farmer has to pay 100% interest for a loan he obtains for his cultivation purposes, how can we expect him to buy sufficient food for his family? While accepting realities of our involvement in various specialized fields, such as health, when coming down to the realities of community poverty and ill-health let us not forget the need to liberate them from social, economic and political structures that are unjust. Consequently, a psychological, methodological and structural change is very necessary to bring about community progress.

One last word. I was talking about the environment. I think environment not only includes air or soil or water but it also includes very much the mental and psychological atmosphere we live in. There is a terrific pollution that is taking place in our psycho-sphere. There is an increasingly prevailing pollution taking place in our minds as a result of greed, hatred and ignorance that we nurture in this world. Therefore, all these things I was talking about have to happen in an environment where the spiritual values have to be brought to the fore-front in our times too. Especially those of us who live in the Asian Region have to remember this. Let me repeat what Dr. Herat Gunaratne said:

‘May all beings be well and happy
May no harm fall on anybody
May we look only at the good of others
May nobody suffer because of my actions’

This should be all the time in the foremost of our minds. I believe a spiritual reawakening of mankind is as much a crying need if we are to advance our target from the year1977 to 2000.