3. Over forty-five women in rural South Indian Panchayat met in early June 2006 to
enlist for various jobs in a proposed export tailoring unit. The tailoring unit is their
goal for income generation and for creating a better life for them and their children.
The Healthy Districts Project assisted the women to identify their inherent
resources and to decide on their goal. The Project is now working alongside them
to mobilise and link the resources necessary for them to realise their goals.
As the group reaches out to women in other communities, and as external
resources are harnessed, the reach of this small project in one community extends
to a District level and provides an example of what can be done across the District
and how District resources can work at a grass roots level.
This is a Healthy Districts Project which is beginning at the local community level
and endeavouring to scale up and reach out. It is working on the belief that if fullest
participation is to be achieved, work must start where people feel they belong and
can be powerful – at their local community level; and that resources are maximally
appropriate and responsive if local people harness them for their development
goals.
This is a Report of the first steps in a long-term Healthy Districts Project.
4. The Healthy Districts Project has three partners and is funded by the Myer Foundation.
The support of the Myer Foundation is gratefully acknowledged.
THE UNIVERSITY OF SOUTH AUSTRALIA
School of Social Work and Social Policy
MADRAS CHRISTIAN COLLEGE
Department of Social Work
CHRISTIAN MEDICAL COLLEGE
Rural Unit for Health and Social Affairs
THE MYER FOUNDATION
In this, the first four-month stage of a three year project, there are already documented
indications of change towards the objectives of the project: higher participation by
members of the community; collective action; women’s empowerment; and strategies in
place to raise levels of income.
These changes are occurring in one part of a larger area. The larger area overall has
progressed in terms of health and socioeconomic status over the past 30 years.
However, in the particular area where the project is currently working, the poverty rate
and the infant mortality rate have remained relatively high.
The changes noted above are encouraging for the participating communities and in
terms of the project objectives. They also are building a testimony to the ways in which
health is determined by social and structural factors, to the power of ‘bottom up’
community development and the importance of non-health sector involvement in health.
5. 1
TABLE OF CONTENTS
ACKNOWLEDGEMENTS 5
1. INTRODUCTION 7
THE PROJECT SETTING 8
TAMIL NADU 8
VELLORE DISTRICT 10
KV KUPPAM BLOCK 10
ALANGANERI PANCHAYAT 12
ALANGANERI PANCHAYAT MAP 14
STRUCTURE OF THE REPORT 15
2. STAGE ONE ACHIEVEMENTS AND OUTCOMES 16
PROJECT OBJECTIVES 16
ACHIEVEMENTS AND OUTCOMES 17
ETHICS APPROVAL 17
TEAM TRAINING AND CAPACITY BUILDING 17
BASELINE SURVEYS 17
ENTRY INTO THE COMMUNITY AND RELATIONSHIP BUILDING 17
PARTICIPATORY RURAL APPRAISAL AND APPRECIATIVE INQUIRY 18
STAGE TWO PLANNING 19
COMMUNITY OUTCOMES 19
LEARNING OUTCOMES 19
TOWARDS A HEALTHY DISTRICT – FACILITATING CATALYST MOBILISING RESOURCES
HARNESSING NETWORKS 19
3. HEALTHY DISTRICTS RESEARCH PROJECT OVERVIEW 22
INTRODUCTION 22
AIM AND OBJECTIVES 22
PROJECT RATIONALE 23
PROJECT PARTNERS 24
THREE YEAR TIMELINE 25
BUDGET 26
TIMELINE FOR STAGE ONE OF HEALTHY DISTRICTS PROJECT 27
6. 2
4. THEORETICAL UNDERPINNINGS OF THE HEALTHY DISTRICT PROJECT 30
INTRODUCTION 30
HEALTH AND COMPREHENSIVE PRIMARY HEALTH CARE 32
THE HEALTH DEBATE JOURNEY TO 2006 34
HEALTHY DISTRICTS IN SOUTH EAST ASIA 39
SOCIAL DETERMINANTS OF HEALTH 42
HEALTH, DEVELOPMENT AND HUMAN RIGHTS DISCOURSES 44
SOCIAL CITIZENSHIP AND GOVERNANCE IN HEALTH 46
CONCLUDING REMARKS 47
5. APPRECIATIVE INQUIRY (AI) 48
THE STAGES OF AI 48
DISCOVERY STAGE 50
EVALUATION OF THE DISCOVERY STAGE 50
DREAM STAGE 50
EVALUATION OF THE DREAM STAGE 51
DESIGN STAGE 52
EVALUATION OF THE DESIGN STAGE 52
DELIVERY STAGE 53
6. PARTICIPATORY RURAL APPRAISAL 54
7. METHODOLOGY 55
PROJECT AIM AND OBJECTIVES 55
METHODOLOGY 55
SAMPLING SELECTION OF THE TWO CASES STUDY 56
COMPARATIVE CASE STUDIES RESEARCH DESIGN 56
ACTION RESEARCH 57
BASELINE SURVEY OBJECTIVES 58
SAMPLING TECHNIQUES – SYSTEMATIC SAMPLING OF THE BASELINE SURVEY 59
BASELINE SURVEY TECHNIQUES 59
CONFIDENTIALITY – CONSENT 60
DOCUMENTATION 60
ETHICS 60
8. BASELINE SURVEY 61
BASELINE DATA COLLECTION 61
INSTRUMENT AND DATA PROBLEMS, SERIOUS FLAWS 62
THEMATIC ANALYSIS 63
DATA ENTRY 63
DATA ANALYSIS 64
ALANGANERI (INTERVENTION PANCHAYAT) AND MURUKAMBATTU (COMPARISON
PANCHAYAT) COMPARED 64
ALANGANERI PANCHAYAT AND MURUKAMBATTU PANCHAYAT – SOME PATTERNS 70
POVERTY INDICATORS 70
RESOURCE UTILISATION 71
7. 3
SOCIAL CAPITAL, EMPOWERMENT AND GOVERNANCE 71
ALANGANERI OVERALL, METTUKUDIPATTI AND THE HARIJAN COLONY COMPARED 72
ALANGANERI OVERALL, METTUKUDIPATTI AND THE HARIJAN COLONY – SOME
PATTERNS 79
POVERTY INDICATORS 79
RESOURCE UTILISATION 80
SOCIAL CAPITAL, EMPOWERMENT AND GOVERNANCE 81
SOME RELATIONSHIPS ACROSS VARIABLE IN THE ALANGANERI PANCHAYAT 82
FURTHER THEMES FROM THE BASELINE SURVEY PROCESS 88
CONCLUSION 91
9. STAGE ONE PROCESSES 92
IDENTIFICATION AND SELECTION OF HEALTHY DISTRICTS PROJECT CASE AREA 92
PSU 2005 MORBIDITY RATES 93
DISCUSSIONS WITH RURAL COMMUNITY OFFICERS 97
DISCUSSIONS WITH TRAINING OFFICERS, SENIOR TRAINING OFFICERS AND HEAD, RUHSA 98
INTERVENTION AND CONTROL/COMPARISON PANCHAYATS 98
TEAM CAPACITY BUILDING 99
BASELINE SURVEY IN INTERVENTION AND CONTROL PANCHAYATS 100
CHOOSING THE SAMPLING METHOD FOR THE BASELINE SURVEY 100
ENTRY INTO THE PANCHAYAT COMMUNITIES 101
MYRADA CONSULTATION 102
PROCESS OF AI AT METTUKUDIPATTI IN APRIL AND MAY 2006 102
GROUP COMPOSITION AND SIZE 103
LOCATION 103
TEAM MEMBER ROLES 103
TIMING 104
THE DISCOVERY STAGE OF AI IN METTUKUDIPATTI 104
PICTURES OF THE VILLAGE MAPPING 105
EVALUATION OF DISCOVERY STAGE 109
DREAM STAGE 111
EVALUATION OF THE DREAMING STAGE 119
DESIGN STAGE 121
EVALUATION OF THE DESIGNING STAGE 124
10. INSIGHTS AND LEARNING 125
THE CENTRALITY OF LEARNING IN THE HEALTHY DISTRICTS PROJECT 125
LEARNING IN HEALTHY DISTRICTS PROJECT 126
WORKING WITH INTERPRETERS 127
MANAGING COMMUNITY EXPECTATIONS 128
RCO INVOLVEMENT IN COMMUNITY PROCESSES/ROLE DELINEATION 130
FOCUS OF HEALTHY DISTRICTS PROJECT INTERVENTIONS 131
RESEARCH INSTRUMENTS VERSUS INFORMATION GATHERING THROUGH AI AND PRA 133
THE DIFFERENT PERSPECTIVES OF HEALTH AND THE HEALTHY DISTRICTS PROJECT
APPROACH 135
THE SCOPE OF THE HEALTHY DISTRICTS PROJECT – GREATER THAN ANY ONE LOCAL
COMMUNITY 136
IMPORTANT FIGURES IN THE PROCESS 137
POWER AND STATUS 138
WORKING IN A TEAM ENVIRONMENT 141
8. 4
11. ENDINGS…BEGINNINGS 143
REITERATING ACHIEVEMENTS AND OUTCOMES 143
INDICATORS OF ACHIEVING OBJECTIVES TO DATE 144
SPENDING 147
SPENDING 148
SOME NEXT STEPS FOR THE NEXT TEAM(S) 149
REFERENCES 151
APPENDICES 155
APPENDIX 1 BASELINE SURVEY INTERVIEW SCHEDULES: ORIGINAL, TAMIL AND
MODIFIED FORMS 156
APPENDIX 2 PLANS AND CONDITIONS DOCUMENT 171
MRS MIRIAM SAMUEL 181
MADRAS CHRISTIAN COLLEGE, UNIVERSITY OF MADRAS 181
DATE: 181
APPENDIX 3 FREQUENCIES OF VARIABLES IN ALANGANERI PANCHAYAT,
MURUKAMBATTU PANCHAYAT, METTAKUDIPATTI AND ALANGANERI HARIJAN COLONY
182
FREQUENCY TABLES AND CHARTS FOR ALANGANERI PANCHAYAT 182
FREQUENCY TABLES AND CHARTS FOR MURUKAMBATTU PANCHAYAT 202
FREQUENCY TABLES AND CHARTS FOR METTAKUDIPATTI 217
FREQUENCY TABLES AND CHARTS FOR HARIJAN COLONY 236
APPENDIX 4 RUHSA DEMOGRAPHIC AND SOCIO-ECONOMIC SURVEY, MARCH 2004 254
APPENDIX 5 AI SESSION NOTES – DOCUMENTING THE PROCESS 258
9. 5
ACKNOWLEDGEMENTS
Healthy District is only as healthy as the quality of collaboration and support
offered by a wide range of people and organisations. The progress which has
so far been achieved in this, the first stage of the Project is the outcome of a
wide range of people who have invested their time, support and faith in the project
and in the team of Stage One of the Healthy Districts Project. We wish to thank the
following and to acknowledge their contributions to the Objectives of the Project:
The participants in Alanganeri and Murukambattu Panchayats’ baseline survey.
Their responses have enriched our understanding of their communities;
administering the surveys was our first entry into these communities.
The Mettukudipatti Self Help Group animator, group members and other
members of Mettukudipatti who have inspired us with stories of their
achievements and impressed us with the strengths they have. We have
formed close relationships with these people and have great confidence they
will achieve their dreams. Their generosity, love and friendship will last.
The President of Alanganeri Panchayat who welcomed us into the Panchayat
and who has supported our work to date.
The Healthy Districts Reference Group for its guidance and insights along the
way.
Mr Prince Annadurai for his incisive questions and observations of our work as
a co-investigator.
Mr Prince Solomon, Mr Prince Annadurai and the senior Master of Social Work
students of Madras Christian College who, through their involvement in the
Baseline Survey also contributed very significantly to the learning of the Project
team and to providing directions for and insights into important issues facing
the Project.
Mr Jambalingam for his continued support and guidance which comes from
long and very special experience in working in development and in the KV
Kuppam Block.
Mr Govinderaj and Mr Ganesan for their support and sharing of their expertise
and expertise in working with communities in the KV Kuppam Block.
Mr D Immanuel for his guidance on organizational matters as well as his
support and advice in many other areas relevant to our activities and our
relationship with RUHSA.
Mr Jebaraj for his consistent interest and guidance, sharing of his long
experience in development work and for the links he has made for us with
resources in the District.
Mr Sanjeevy for his patience in guiding us through the arrangements in relation
to the administration of the funding.
A
10. 6
Saleela Patkar, of MYRADA, for sharing her wisdom and giving us timely and
valuable guidance in Appreciative Inquiry practice.
The RUHSA faculty for their orientation and training in Participatory Rural
Appraisal.
Dr KR John for his considerable support and for modeling good Healthy
Districts participation by mobilising RUHSA resources for the development of
the communties in the Alanganeri Panchayat .
Dr T. Thasian, of RUHSA, for his guidance in methodological issues and his
feedback on and suggested changes to the draft Baseline Interview Schedule
which led to the final form of the Schedule.
The Myer Foundation for its financial support of the Project.
Children
performing with
dancing from
popular Tamil
cinema
11. 7
1. INTRODUCTION
his Report documents the first four months of a three year Healthy Districts
Project in the Vellore District in Tamil Nadu, South India.. The Project aims to
change the health status of communities within a District through social and
economic development strategies, cognizant of the strong evidence about social and
economic determinants of population health.
The World Health Organisation’s contributions to understanding and addressing
health holistically over the years since 1978 have included such initiatives as Health
for All by the Year 2000, comprehensive primary health care, its healthy settings
approach and the latest contribution, the Commission on the Social Determinants of
Health. The work of the World Health Organisation has been firmly based on a
growing body of evidence and knowledge about the nature of health and illness.
It is now readily acknowledged in theory that the health status of communities is
determined by social, economic and political factors, as well as by individual
biological and behavioural factors. Poverty, as an economic and political factor, and
inaccessibility to resources, as a social and political factor, are just two of the many
social determinants of health. However, this knowledge has not so readily been
translated into policy or programs.
In recent years, the World Health Organisation South East Asian Regional Office has
developed the Healthy Districts approach, as one approach within the broader World
Health Organisation healthy settings concept. This Report is a report of the first
stage of the Healthy Districts Project.
The project draws on a range of knowledge. The project is firmly based on a set of
principles, namely those which comprise comprehensive primary health care. These
principles help enrich understanding and guide practice. They include equity,
access, participation, intersectoral collaboration, acceptability, affordability, human
rights and so on. The project also draws on the more theoretical areas of social
health, governance and citizenship to build a conceptual understanding of health and
its contributing factors. This understanding also identifies the factors that need to be
addressed in health promotion program terms. Finally, the project draws on practice
knowledge, most notably community development, participatory rural appraisal and
appreciative inquiry, to develop health promoting strategies and interventions to
create change and influence the health status of the communities in which the project
is operating.
The project is a collaborative action research project between the School of Social
Work and Social Policy of the University of South Australia, the Department of Social
Work of the Madras Christian College and the RUHSA Department of Christian
Medical College, Vellore.
The “on the ground” project teams comprise Australian social work students
undertaking four month long placements at RUHSA. The “stages” of the Project are
thus delineated according to the consecutive batches of students who will be the
project teams through the life of the project. The first team, comprising Emmanuelle
T
12. 8
Barone and Andy Umbers, have worked from February to June 2006. These two
students will always have a special position in the project because they initiated it in
the Alanganeri Panchayat communities in the Vellore District. Their work has helped
set directions for future work. More importantly, however, their honest and reflective
approach to their work and their openness to learning and risking the unknown has
enabled rich learning to occur, and wonderful progress to be achieved already in the
community in which they have worked.
This Report records the foundations of the project and its processes, progress and
learning to date.
The Project Setting
The Healthy Districts Project is set in the Alanganeri Panchayat, KV Kuppam Block,
Vellore District, Tamil Nadu, India. This is a rural setting in south India.
Tamil Nadu
Tamil Nadu has a population of some 65 million people. The following table gives an
idea of some of the socioeconomic features of Tamil Nadu and also provides some
comparisons with India as a whole.
Compared to India as a whole, Tamil Nadu:
Tamil
Nadu
13. 9
Is more densely populated.
Has a better female:male ratio.
Has more scheduled caste (dalit) people.
Has considerably less tribal people.
Has lower birth, death and infant mortality rates.
Has a better literacy rate for both men and women.
Has relatively fertile land, as indicated by the average yield of rice.
Has more widespread electrification throughout its rural areas.
Has slightly better participation rates in education.
SELECT SOCIO ECONOMIC INDICATORS OF TAMIL NADU AND INDIA
Economic Indicators Tamil Nadu India
Area ('000' Sq.Kms) (2001 Census) 130 3287
Population ( in Million) (2001 Census) 62.4 1029
Rural 34.9 742.7
Urban 27.5 286.1
2006 65.0 1094.1
2011 67.6 1178.9
Projected
2016 69.9 1263.5
Density (Population per Sq.Kms) 480 325
Sex Ratio ( Females per 1000 Males) (2001 Census) 987 933
Urban Population Percentage (2001 (P)) 43.86 27.78
Scheduled Caste Population as Percentage of Total
Population 2001
19.0 16.2
Scheduled Tribe Population as Percentage of Total
Population 2001
1.0 8.2
Birth Rate 2003 18.3 24.8
Death rate 2003 7.6 8.0
Infant Mortality Rate 2003 43 60
Persons 73.5 64.8
Male 82.4 75.3Literacy Rate - 2001
Female 64.4 53.7
Average Yield of Rice 2002-03 (Qtls. per Ha) 33.5 18.0
Per capita Consumption of Electricity (KWH.) 2002-03 815 567
Rural Electrification - As on 31.03.2003
Villages Electrified (Percentage) 100.00 83.80
Pumpsets Energised (in '000) 1676 13792
No. of Students in Primary and Secondary Schools per
1000 Population (30-9-2000)
175 172
Source : Respective Heads of Department, Statistical Abstract of India - 2003
Statistical Outline of India - 2003-04
Tamil Nadu Electricity Board Statistics at a Glance 2003-04
Banking Statistics Quarterly Handout - March 2005.
14. 10
Centre for Monitoring Indian Economy (CMIE), November 2004
Vellore District
The Vellore District lies to the North East of the state of Tamil Nadu, on the
border with Andhra Pradesh.
KV Kuppam Block
The KV Kuppam Block has a population of about 130,000. It has been serviced by
the Rural Unit for Health and Social Affairs (RUHSA) since about the time of the
Declaration of Alma Ata, the introduction of comprehensive primary heath care and
the strategy of Health for All by the Year 2000. Originally this Block was chosen as
the site for RUHSA because of its low health and development indicators within the
Vellore District.
The KV Kuppam Block is situated 130 kilometres from Chennai, 27 kilometres west
of the town of Vellore (population 390,000) and 12 kilometres east of Guddyatam.
The KV Kuppam Block has 39 Panchayats, in which each has their own main village,
harijan (dalit, outcaste) colonies, hamlets and scattered field huts. RUHSA covers the
entire Block in terms of health care, weekly mobile health care clinics, health
education programs, social welfare schemes and social and economic development
activities. Statistics show that of the 130,000 population, 75% live below the official
poverty line and almost one-third belong to scheduled castes.
Vellore
District
15. 11
The consistent health and development work of RUHSA is testimony to the
effectiveness of viewing health socially as well as physically. The following statistics
give an indication of the changes that have been possible through the work of
RUHSA. These compare most favourably with adjacent Blocks in the District.
Some key indicators of change in KV Kuppam Block are:
Indicators 1978 2004
Proportion of households below US$1 (PPP*) 89.4% 42.4%
Reduction in underweight 44.6% 17.2%
Reduction in stunting 41% (1983) 24% (2001)
Completing 5th
standard
Male
Female
-
-
93.3%
98.6%
Literacy rates of 15-24 years old
Men
Women
47%
21%
86%
82%
Crude birth rate (per 1000 population) 32.0 14.4
Infant mortality rate (per 1000 live births) 116.0 26.4
Under 5 mortality rate (per 1000 live births) 87.0 (1988) 32.7
Maternal mortality - 271 (1999-
2003)
KV Kuppam Block
16. 12
However, within the Block, there is variation in health and socioeconomic indicators.
One of the poorer and less healthy of these areas is the Alanganeri Panchayat.
Alanganeri Panchayat
The Alanganeri Panchayat comprises a main village, hamlets, field huts and two
colonies. The colonies are inhabited by Harijans, or outcastes, who are known also
as Dalits. There are an estimated 160 million Harijans in India and 10.7 million in
Tamil Nadu, of which 5.4 million are women. In Tamil Nadu, the majority of Harijans
live in the Nilgiris Districts and relatively few in the Vellore District.
Living in separate colonies, Harijan communities generally have less basic amenities
(such as toilets), live in greater poverty, are relegated to the most menial tasks and,
being largely landless, are economically dependent on caste people for income.
Income security and food security are generally less than for caste people, with many
Harijans relying on coolie work, daily work in fields and other areas. This work is both
seasonal and unreliable. Payment can be in grain rather than in cash. There is a
history of discrimination against Harijans.
As stated earlier, Alanganeri Panchayat is one of 39 Panchayats in the KV Kuppam
Block. The Panchayat is the local level of the three tier government system in India,
the other two levels being the state and central (national) levels. Alanganeri
Panchayat is 6 kms from RUHSA CSU and about 2.5-3 kms from the main Katpadi-
Guddiyattam road. The Panchayat consists 439 households (414 of which were
RUHSA
Alanganeri
Panchayat
KV Kuppam Block showing RUHSA and Alanganeri Panchayat
17. 13
occupied as of March 2006) which are situated in a main village (73 households),
hamlets, scheduled caste (Harijan, Adidravidari and Arunthathi) colonies (123
households), and 34 field huts. These are all within close proximity of each other.
The caste system in India is a complex system and there are thousands of castes
and sub-castes throughout the sub continent. The Indian government has determined
a limited number of categories into which castes are placed, for the purpose of
access and equity policies and practices, such as reserved places in education,
public employment and so on. These categories are:
Forward Castes (FC)
Backward Castes (BC)
Most Backward Castes (MBC)
Scheduled Castes (SC)
Scheduled Tribes (ST).
Alanganeri Panchayat consists of MBCs and SCs. 90% of people are of the Vanniyar
caste, which is an MBC. The inter-caste relations are generally good, with castes
interacting with each other and participating in others’ celebrations and festivals.
The caste distribution is as follows:
Main village Vanniyar MBC
Vasanthapuram Vanniyar MBC
Mettukudipatti Vanniyar MBC
Mandakannanpatti Vanniyar MBC
Buddammalpatti Vanniyar MBC
Sempattarai Vanniyar MBC, SC and Achari
Alanganeri HC Adidravidar SC
Alanganeri AC Arunthathiyar SC
Sottaikarveeda Arunthathiyar SC, HC, Reddy, AC
China Alanganeri Gounder, AC, HC, Reddy
There are 7 women’s self help groups in the Panchayat. Each of these groups has
the maximum number of 20 members, so there are 140 women who are members of
self help groups. None of these groups has income generation programs in place.
Any income generation programs in the Panchayat are individual programs and
mainly related to ancillary farming activities.
In terms of religion, 99% of the Panchayat population is Hindu and about 1%
Christian. There are no Muslims in the Panchayat.
19. 15
Structure of the report
The report is written by the first project team. Accordingly when the report refers to
this team we will use second person pronouns, “us”, “we” and so on. With reference
to future teams, they will be referred to as teams.
The structure of the report is as follows:
Healthy Districts Overview
Theoretical Foundations
Healthy Districts Approach
Methodology
Stage One Processes
Stage One Results
Stage One Learning
Conclusion
Recommendations and next steps
Children’s
participation
contributes to a
community’s social
capital stocks
20. 16
2. STAGE ONE ACHIEVEMENTS AND OUTCOMES
ccording to the original proposed timeline of the Healthy Districts Project, the
outcome of Stage One was intended to be up to and including the completion
of the baseline survey in the intervention and comparison Panchayats. The
achievements and outcomes of Stage One have, in effect, far surpassed orginal
expectations. That this is the case is the result of the commitment of the team and
the nature of the community with which we are working and its people. Communities
are so often approached to ‘solve their problems’ and in so doing they are viewed as
weak. Approaching a community with a firm belief in its strengths and resources
allows those strengths and resources to quickly come to the fore. This has certainly
been the experience to date in this Project.
Before embarking on the details of the Project, a summary of achievements and
outcomes are listed and described below.
This Section therefore serves the function of an Executive Summary.
Knowledge of the results of Stage One will enable the reader to understand where
each of the components parts are leading, as he or she reads each part and each
Section of the Report.
Although the Project objectives will be discussed later in the Report, at the risk of
repetition, they are also listed here to contextualise the achievements and outcomes
of Stage One.
Project Objectives
The project aims are to develop and evaluate the social health outcomes of a World
Health Organisation Pilot Healthy District project, and in particular –
To ascertain the effect of health and development interventions on the heath
status of local rural communities in the KV Kuppam Block of Vellore District,
Tamil Nadu, namely community development/community-based strategies
utilising Participatory Rural Assessment and Appreciative Inquiry.
To develop and evaluate community-based interventions for application in rural
communities. These interventions involve:
(1) the development of a partnership (as a major means of community
participation) between community members and researchers;
(2) within which issues of importance to the communities are jointly identified;
(3) strategies to address the issues agreed upon and
(4) the outcomes of these strategies measured/evaluated in terms of extent of
achievement of relevant goals.
To strengthen the capacity of local communities to promote and maintain
health through:
A
21. 17
(1) the establishment of community structures, such as women’s self help groups,
health committees, youth groups, and any other structures appropriate to
issues identified; and
(2) which are substantially led, organised and maintained by local community
members;
(3) who together hold appropriate and sufficient skills (eg meeting skills, advocacy
skills, organisational skills…) to ensure the structures are durable over time.
Achievements and Outcomes
Ethics approval
Approval from the respective Ethics Committees of the University of South Australia
and the Christian Medical College, Vellore have been received.
Team training and capacity building
The first team in the Project, the Stage One team, were trained in Participatory Rural
Appraisal techniques and in the Appreciative Inquiry Method. This took place over
five days at RUHSA, run by the RUHSA Faculty and the Principal Investigator. A
consultation meeting with MYRADA, an expert Appreciative Inquiry organisation in
Bangalore, was also conducted.
Baseline surveys
Both baseline surveys, one in the intervention Panchayat, Alanganeri, and one in the
comparison Panchayat, Murukambattu. The baseline survey was designed in
consultation with Dr Thasian. After the administration of the survey in Alanganeri, the
instrument was modified in two respects. Firstly, some questions were deleted,
particularly those pertaining to monthly expenses and income. The data collected in
Alanganeri was largely unusable because of a range of factors to be discussed later.
Secondly, for ease of entry into SPSS, some questions were redesigned so that
categories could be immediately ticked (See Appendix 1). While it can be argued
this gives rise to methodological problems, both in the baseline data and for the post
test in three years’ time, we would strongly argue that, on balance, the increased
usefulness of information as a result of the modifications outweighs methodological
concerns. The project is an action research project and this allows for flexibility and
responsiveness if greater utility is gained.
Entry into the community and relationship building
We have established relationships with a range of people who are part of the
communities in the Panchayat, including relevant RUHSA staff, the Panchayat
President, members of the women’s self help group, other community members and
some of the people and organisations that have resources which are of potential use
in achieving the aims of the community and the objectives of the Project. We are
confident that high levels of reciprocal support, trust and hope are central features of
many of these relationships. There are other key people that have not yet been
approached and need to be, such as the Block Development Officer and staff.
22. 18
With entry into the community, we have built our knowledge about many aspects of
the community, particularly the strengths, resources and aspirations of its members.
Participatory Rural Appraisal and Appreciative Inquiry
In Mettukudipatti, one of the villages within the Alanganeri Panchayat, we have been
able to move through significant stages of Appreciative Inquiry and to engage in
some Participatory Rural Appraisal techniques.
In particular, we and local people have developed an attractive village map which
clearly depicts the pride that people have in their village and community. This map
has been reproduced as a plastic banner to enable it to be durable and visible in the
village, as appropriate.
We have also moved through the AI Stages of Discovery, Dreaming and Designing in
Mettukudipatti. This process has led to action planning and work on two issues of
importance to the local people, namely establishing a collective, community
tailoring/garment making tailoring unit (the interpreter has used the word ‘tailoring
unit’ but because this may convey an idea of a very large manufacturing business,
which is not the intent of the community group, the term ‘unit’ will be used forthwith),
and enabling them to learn to speak English fluently.
Entering the
community –
meeting the
Panchayat President
23. 19
Stage Two Planning
Based on our commitment to ensuring that the poor and marginalised groups are
included in the benefits of a Healthy District, we have made the decision that the
Harijan Colony will be the next community in the Alanganeri Panchayat in which the
Project will work. This will be one of the foci of the Stage Two team who will
commence work in late July 2006.
Community outcomes
The achievements to date have led to community outcomes that are consistent with
the Project Objectives. Strong partnerships are now formed, especially in
Mettukudipatti. Issues of importance to the community have been identified.
Strategies are being put in place to meet the aspirations of the villagers.
While the self help group in Mettukudipatti was pre-existing as a strong group, its
capacity to create a collective income generation program and to move beyond only
a micro credit function for its members, is evident. The skills necessary to run a
garment unit are being progressively identified. Strategies are being put in place and
resources mobilised to ensure that the local people have the skills to manage a unit
and to produce high quality products.
It is clear that the achievements to date have progressed the objectives of the
Project. Furthermore, these have been progressed well beyond what was expected
when the timeline for the three years was drawn up in 2005.
Learning outcomes
We have learned much. We have attempted to name and document what we have
learned so that this may be passed on to others, especially the future project teams.
These learning outcomes are detailed in a subsequent part of this Report.
Towards a Healthy District – facilitating catalyst mobilising
resources harnessing networks
While the Project activity in Stage One has been substantially in one village, the
Healthy District spirit and focus has neither been forgotten nor lost. In fact, local level
work has been a deliberate Healthy Districts strategy. It is our belief, backed by a
strong body of literature, that ‘bottom up’ community development is most effective.
In working with one village, we have deliberately identified, harnessed and mobilised
wider, District level resources. These have included the potential resources of
buildings, land, building materials, training facilities and equipment from outside the
village and within the Vellore District.
In this way we have not provided services or resources to the community. We have
facilitated processes, we have been a catalyst for existing networks to swing into
action and share resources and we have enabled the mobilisation and harnessing of
resources to build a healthy community that will have the capacity to contribute to its
neighbouring communities and so to a Healthy District.
24. 20
The diagram on the following page depicts some of the main activities of Stage One
and their reach – either within Mettakudipatti village, beyond to the Panchayat, the
Block, the District or wider. This reflects the approach to building a Healthy District,
beginning with one local community and scaling up while maximising community
participation.
Activities as well as
talking ensure fuller
participation in
discovering, dreaming…
25. 21
Vellore
District
KV Kuppam
Block
Alanganeri PanchayatMurukambattu
Panchayat
26 May 2006 – linking to other successful
Block projects
SHG
with no
Income
February 2006 – negotiating support
role by RUHSA
March 2006 – gaining
support of Panchayat
P id t
March, May 2006 – collecting baseline
data in Alanganeri and Murukambattu
P h t
March 2006 – consultation with MYRADA, Bangalore
March to June 2006 –
Appreciative Inquiry
Process
March to June 2006 –
Planning
Garment/Tailoring Unit
March to June 2006 –
Planning classes for
learning to speak fluent
English
May 2006 – Gaining support
of Rajagopal Polytechnic
College, Gudiyattam
26. 22
3. HEALTHY DISTRICTS RESEARCH PROJECT
OVERVIEW
Introduction
n 2001 the World Health Organisation South East Asian Regional Office
commissioned the production of a Concepts and Strategies Paper on a Healthy
Districts Approach to health within rural settings in the region. This approach was
further development of the World Health Organisation’s healthy settings approach
and was intended to provide guidelines for community participation and intersectoral
collaboration at the rural District level.
This Healthy Districts Research Project is an action research/development project
which works within the principles of the World Health Organisation Healthy Districts
approach. However, it is distinguished by its additional principle of adopting a clear
‘bottom up’ approach to its development work.
The project aims to encourage the development of specified parts of the Vellore
District, Tamil Nadu, India with the intention of increasing the population health status
in those areas. The project will measure health status before and after a period of
three years, within which two forms of health intervention will be introduced. The
project is being carried out within the World Health Organisation Healthy Districts
approach, using community development methods. The project commenced in July
2005 (project planning) and will extend to December 2008 (final report).
The project is a collaborative one amongst three core partners in Australia and India
– the School of Social Work and Social Policy University of South Australia,
Department of Social Work, Madras Christian College and the Rural Unit for Health
and Social Affairs (RUHSA). The relationship between the partners is detailed in the
Plan and Conditions document developed in the first phase of the project (See
Appendix 2). To date this was endorsed by RUHSA and Madras Christian College in
March 2006 and signing of the document is pending a response from the University
of South Australia.
Aim and Objectives
The project will ascertain what health and development interventions contribute
towards improved population health status in a rural area in South India. The project
will also facilitate action, in particular community and civil society organisation
(NGO/CSO) action, to increase their capacity, beyond the project period, to engage
in sustainable health improvement and development activities and projects.
The World Health Organisation’s Healthy Districts approach, which is part of its
Healthy Settings approach to health, forms the basis of the project. This World Health
Organisation approach is based on a social view of health. It gives a central position
to intersectoral collaboration between Civil Society Organisations (CSOs/NGOs) and
I
27. 23
to community participation, in the identification of health needs and the planning,
implementation and evaluation of strategies to identify and address needs.
The project aims are to develop and evaluate the social health outcomes of a World
Health Organisation Pilot Healthy District project, and in particular –
To ascertain the effect of health and development interventions on the heath
status of local rural communities in the KV Kuppam Block of Vellore District,
Tamil Nadu, namely community development/community-based strategies
utilising Participatory Rural Assessment and Appreciative Inquiry.
To develop and evaluate community-based interventions for application in rural
communities. These interventions involve:
(1) the development of a partnership (as a major means of
community participation) between community members
and researchers;
(2) within which issues of importance to the communities
are jointly identified;
(3) strategies to address the issues agreed upon and
(4) the outcomes of these strategies measured/evaluated
in terms of extent of achievement of relevant goals.
To strengthen the capacity of local communities to promote and maintain
health through:
(1) the establishment of community structures, such as
women’s self help groups, health committees, youth
groups, and any other structures appropriate to issues
identified; and
(2) which are substantially led, organised and maintained
by local community members;
(3) who together hold appropriate and sufficient skills (eg
meeting skills, advocacy skills, organisational skills…)
to ensure the structures are durable over time.
Project Rationale
Tamil Nadu, India, has had a long history of health care provision in rural and urban
communities. A project which identifies the factors which contribute to a higher
population health status at the Block and District levels can assist the work health
policy makers at the State and district levels, health professionals and local
communities, to achieve better health for people in rural areas where access to
professional health care services are often limited. This knowledge, in turn, can
assist policy makers and providers to more strongly advocate for health funding and
to further improve the planning and implementation of comprehensive primary health
care, and so improve the health status of communities in Tamil Nadu.
The World Health Organisation considers the application of the Healthy Settings
process at the district level in rural areas in South and South East Asian countries as
particularly desirable, considering that the added utility of a Healthy Districts
approach for the World Health Organisation collaborative effort would constitute
strengthening countries’ capacity for integrated management, promotion of health
28. 24
systems research and demonstration of the effects of technical inputs being used at
the district level.
In the Vellore District of Tamil Nadu, RUHSA has been involved in comprehensive
primary health care in the KV Kuppam Block for the past 27 years.
It would be reasonable to expect that a Healthy Districts project such as this one
would encompass an entire rural district. However, that is not the case for this
project. This is for two reasons. The first reason is the pragmatic reason of limited
resources, which preclude playing a substantive role across many communities
within a district. The second reason relates to the belief in and commitment to a
“bottom-up” approach to health and development. (Ife and Tesoriero 2006). People in
rural India are members of strong communities. However, the communities to which
people generally identify do not easily align with a District. Within districts are
Panchayats, the unit of local government in India; and within Panchayats are villages,
hamlets and colonies. People strongly identify with the village level and easily identify
with their Panchayat. Consequently, the approach of this project is to work at the
Panchayat level, and within it, in certain targeted villages, hamlets and colonies. It is
at this level that community participation is most likely to be maximised, both in terms
of numbers of participants and in terms of empowerment of people to effect change.
This focus, however, does not neglect the wider context.
While the very local level provides the best opportunity to engender community
participation, most of the formal and other resources for health and development are
at the District level. So, the project will deliberately work to mobilise appropriate
resources at the District level, both government and NGO resources, as well as the
expertise and experience of other local communities who have engaged in health
and development activities and processes. This Panchayat level project which also
mobilises district level resources, will document both processes and outcomes such
that other local communities within the district can embark on similar processes and
so the reach of the local level Healthy Districts Project can reach across other
Panchayats to cover a whole district. Thus the project remains a Healthy Districts
project, even though its coverage is more limited in its first three years.
Project Partners
The core project partners are:
1. School of Social Work and Social Policy,
University of South Australia.
2. Department of Social Work, Madras Christian College,
Tambaran.
3. RUHSA (Rural Unit for Health and Social Affairs)
Christian Medical College, Vellore.
29. 25
The Myer Foundation provided the funding for the project.
Apart from the core members, the following play consultative or advisory roles as
requested:
1. Professor Koteswara Prasad,
Department of Public Administration and Politics,
Madras University, Chennai.
2. Dr Fr S. Thanislas,
Department of Social Work,
Sacred Heart College, Tripattur.
3. Professor Ronald Labonté,
Institut de recherché, sur la santé des populations,
Université d’Ottawa.
Three year Timeline
The timeline of the Project is:
July 2005 to
Mar 2006
Research Planning and Ethics Approval
KV Kuppam Block,
Vellore District
Comparison Case
(Panchayat )
Intervention Case
(Panchayat )
March to June
2006
Baseline data/ pre test
April 2006 to
September
2008
No intervention beyond
existing services
Economic and
social development
Oct to
November
2008
Post test
December 2008 Final report
30. 26
The main phases of the project are:
Research planning and ethics approval by the University of South Australia
Human Research Ethics Committee and the Christian Medical College Ethics
Committee.
Selection of control and intervention Panchayats.
Planning and administration of baseline survey in Panchayats and data entry
and analysis.
Community development processes within the intervention Panchayat.
Administration of post testing in control and intervention Panchayats.
Final report.
As the project team will comprise 6-8 different batches of Australian social work
students over the three year period, there will be reports produced at the end the
work of each batch, both as periodic reviews and as transition/handover tools
between batches. Accordingly, the phases of project team work between February
2006 and November 2008 will be as follows:
Time phase Student batch Tasks
February 2006-June 2006 Student batch 1 Baseline data/ pre test and
commencement of Economic
and social development**
June 2006-November 2006 Student batch 2 Economic/social development
February 2007-June 2007 Student batch 3 Economic/social development
July 2007-November 2007 Student batch 4 Economic/social development
February 3008-June 2008 Student batch 5 Economic/social development
July 2008-November 2008 Student batch 6 Economic/social development
and Post test
** modified from the original intended Batch One outcome of completed Baseline survey only
Budget
AU$8,670.00 has been provided by a Myer Foundation Grant to cover the costs of
local Indian participants. These funds will be administered by the University of South
Australia through the Christian Medical College, Vellore, of which RUHSA is a
Department. Over the three years, most payments will be made to community-based
organisations for the participation of their members in the intervention strategies,
31. 27
particularly the planning, implementation and evaluation of social/economic
development and health education activities.
Budget Item $ Myer
Foundation
Internet costs associated with research and sourcing information @ $1
per hour and av. 5 hours per week
480.00
Phone/fax over three years 350.00
Local travel costs for community members to attend meetings and other
forms of ongoing participation
650.00
Hire of meeting venues, provision of tea/coffee/snacks 360.00
Ongoing postage and printing costs 450.00
Costs associated with submitting journal articles, conference papers
(printing, postage…)
200.00
Printing and disseminating final report 600.00
Photocopying @ 4c per sheet 8,000 sheets 3,200.00
Local travel expenses of teams in District ($25 per team per week – 96
weeks)
2,400.00
TOTAL $8,670.00
Timeline for Stage One of Healthy Districts Project
Week commencing Task/activities
13 February 2006 RUHSA orientation
20 February 2006
Team training/capacity building:
Participatory Rural Appraisal
Appreciative Inquiry
27 February 2006
Consultations with RUHSA staff on
2004 Health and Development Census
Baseline survey interview schedule questions
Sampling techniques
Identification of Intervention and Control Panchayats
6 March 2006
Entry into Intervention (Alanganeri) Panchayat
meeting with Panchayat President, Mr Damodharan
and council members
Interviewing/selection of Interpreters
Administration of Pilot interview schedule
13 March 2006 Data collection – Alanganeri Panchayat
Interview and selection of new Interpreters
20 March 2006
Data collection continued
Data entry into MS Excel
32. 28
27 March 2006
Team meeting for data coding
Data entry into SPSS
Preliminary data analysis
Meeting with MYRADA (Saleela Patkar), Bangalore regarding
Appreciative Inquiry
3 April 2006
Participatory Rural Appraisal in Mettukudipatti – village
mapping
Healthy Districts Project Reference Group meeting
10 April 2006
PRA and Appreciative Inquiry with Kalaimagal Women’s
Self Help Group, Mettukudipatti (Discovery and Dreaming)
17 April 2006
Appreciative Inquiry with Kalaimagal Women’s Self Help
Group, Mettukudipatti (Prioritising Dreaming Visions)
Consultation with Rural Community Officers, Mr Govinderaj
and Mr Ganesan regarding second community to work with in
Alanganeri.
Decision re: second community: Harijan Colony
Stage One Report Writing
24 April 2006
Mettukudipatti Children’s Day
Team member sleepover in Mettukudipatti
Community Dream selection: “community tailoring unit”
(unit)
Stage One Report Writing
1 May 2006
Designing Action Plan for achieving “community tailoring
unit” (unit)
Stage One Report Writing
8 May 2006 Visit to Rajagopal Polytechnic College, Guddiyatam to
ascertain tailoring training resources
First meeting with RCO and Mettukudipatti community
Stage One Report Writing
15 May 2006 Baseline survey in Murukambattu Panchayat by MCC
students
Designing Action Plan for achieving “community tailoring
unit” (unit)
22 May 2006 Designing Action Plan for achieving “community tailoring
unit” (unit) and for Fluent English classes
Visit to Bishopton Tailoring Company, Veppanyeri
Transition and handover to next social work student by
33. 29
Stage One team
29 May 2006
Stage One Healthy Districts Presentation to RUHSA Senior
Staff
Healthy Districts Project Reference Group meeting
Stage One Report Finalisation
Drawing the village
map – helping the
HDP Team to learn
about Mettakudipatti
and its people
34. 30
4. THEORETICAL UNDERPINNINGS OF THE
HEALTHY DISTRICT PROJECT
Introduction
he Healthy Districts Project is underpinned by several theoretical traditions and
perspectives relating to the concept of ‘health’. These have had a long and
strong history. Together they have contributed to a richer understanding of
health as a social, economic and political issue, and one which embraces
fundamental human rights. It is this broad understanding of health that is of central
importance in the Healthy Districts project.
It is unreasonable to expect changes in health indicators such as infant mortality,
child mortality and maternal mortality in a three year period in this type of project.
However, given the evidence which now exists that social, economic and other
structural factors contribute to health status, changes in some of these factors over
the three year period will indicate the extent to which the project has met its ‘health
promoting’ objectives. In other words, poverty is one such structural determinant of ill
health. If in three years, there has been a change in poverty through, say, the
development of a collective income generation scheme in a village, then this will, on
the scientific evidence amassed about social determinants of health, be considered a
contribution to that community reaching a higher health status. In a similar vein,
increased community capacity and increased social capital will be considered
important changes or transformations towards better population health.
The Project engages in action at the local level, in partnership with local
communities. Community members themselves define the resources they possess
for daily living and their own aspirations for social, economic, physical and spiritual
well-being – for health. The voice of local people has been central to the concept of
comprehensive primary health care, which emerged fully in 1978. The concepts of
primary health care evolved earlier than 1978 as it became more obvious that
approaches to health and public health which only included medical and
technological interventions were not addressing inequities in health status within and
between countries. The principles of comprehensive primary health care are an
important foundation of a Healthy Districts approach. Participation, local control,
accessibility, equity, acceptability all play a central role in building a Healthy District.
The struggle to assert health as a social/economic issue and a human right ensued
after the World Health Organisation Declaration of Alma Ata in 1978 and thereafter
through a long period of neoliberalism and globalisation. This period has seen the
dominance of values hostile to health and human rights. But there have also been
powerful forces at play advocating for health as a human right. There have been
impressive case studies such as Kerala, Cuba and China. There are powerful and
growing social movements such as the People’s Health Movement and the World
Social Forum. The struggle since 1978 has not meant the demise of comprehensive
primary health care. Rather it has produced a history of rich debate and unarguable
evidence of, and activists fighting for, health as a social, economic and political issue.
T
35. 31
The work of the World Health Organisation since Alma Ata, while at one level giving
mixed messages about its approach to health, has nevertheless maintained a broad
social view of health. It has instituted a healthy settings approach and more recently
has established the Commission on Social Determinants of Health. This most recent
initiative is based on the assertion that the time is ripe to apply knowledge/evidence
about the social view of health and social movement activity to health policy and
programs.
In a world dominated by the forces and processes of economic globalisation, the
current political science debates which focus on citizenship activities and new forms
of governance are important. These debates reinvigorate the role of ordinary people
in taking power and in participating in democratic decision making. As such, these
debates give great significance to approaches to health which recognise social
determinants and which involve the people most affected by those determinants.
Health has been defined in many ways, including: as ‘not diseased’; as a reserve for
added resilience; as behaviour; as physical fitness; as energy; as social
connectedness; as psychosocial and spiritual well being (Hancock 1990). A critical
and political economy view of health sees health in terms of its distribution across
groups in society and so highlights the inequalities in health status which result from
socioeconomic differences. It also focuses on structural factors that are either
conducive to, or are barriers to health. (Baum 2002; Labonte 1992). The Healthy
Districts project is based upon this social and structural view of health.
The notion of health as simply being the absence of illness is one that is rejected in
this project. This position does not reject the place of medical intervention but rests
on the view that such intervention is not sufficient to achieve health. Accordingly, the
project embraces a broad, social view of health which recognises health as an ideal
to be reached, a state which belongs to both individuals and whole populations.
Within this view, health status is influenced by a range of social, economic, political
and environmental factors. These factors include: income; social status; social
support networks; early years of life; unemployment and working conditions; social
and physical environments; transport; education; gender; social exclusion; food
insecurity; and access to health services (Wilkinson and Marmot 1998; Berkman and
Kawachi 2000).
Health is understood in terms of the ability of people to have access the resources to
meet their aspirations. This understanding gives importance to access, power and
capacity; and makes as the focus of our interest the determinants of health rather
than the state of health itself. The determinants of health become the focus of our
analysis and intervention. This construction of health is well supported in
contemporary literature. The above diagram of the Mandala of health (Hancock and
Perkins 1985) aptly portrays the breadth of health and of its influencing factors.
Consequently, it also depicts the potential breadth of projects which focus on those
influencing factors, as the Healthy Districts approach does.
It is these above theoretical traditions and perspectives which inform the Healthy
Districts Project. These perspectives will be explored more in the following Sections
and their contributions as foundational factors to Healthy Districts will be explained.
The major perspectives and debates are:
comprehensive primary health care;
neoliberalism and economic globalisation;
good health at low cost;
36. 32
World Health Organisation Healthy Districts/Healthy Settings;
Social Determinants of Health;
health and human rights;
social citizenship and governance.
Health and Comprehensive Primary Health Care
The concept of Comprehensive Primary Health Care is perhaps the central and core
foundational platform of Healthy Districts. The World Health Organisation
Conference at Alma Ata in 1978 and the resultant Declaration of Alma Ata
represented a widespread acknowledgement that there were growing inequities
amongst groups within and between countries in relation to their health status. More
specifically, the gap in health status between the rich and poor was significant and
widening, despite all efforts at providing health care. As evidence grew over the
subsequent years, the medical discourse of health as simply the absence of illness
was increasingly challenged. Evidence mounted that health was determined by
environmental, social, economic and political factors, not simply by biological and
individual behavioural factors. The debates on the determinants of health widened
the concept of health beyond only a medical concept to one of human rights. The
World Health Organisation definition of health reflects this comprehensive view of
health. The World Health Organisation states that health:
37. 33
“is a state of complete physical, mental and social well-being, and not
merely the absence of disease or infirmity, is a fundamental human right
and that the attainment of the highest possible level of health is a most
important world-wide social goal whose realisation requires the action of
many other social and economic sectors in addition to the health sector”
(World Health Organisation1978)
The Alma Ata Declaration clearly stated
“that the existing gross inequality of health status amongst populations
within and between countries is politically, socially and economically
unacceptable and is a common global concern
that people have the right to participate individually and collectively in the
planning and implementation of their health care
that governments have the responsibility for the health of their people
which can only be fulfilled by the provision of adequate health and social
measures.”
(World Health Organisation1978)
For the individual, health, within this perspective, is closely aligned with the ability to
achieve one’s potential and to respond positively to the challenges of the
environment; health is a resource for everyday living. The difference in health status
amongst populations is a social justice issue. People’s participation in health is a
right and health itself is a human right. Consequently, health work must involve
addressing social injustice, inequities, lack of access to resources, barriers to
participation and the violation of human rights. Conversely, health work is social
justice promoting, enabling participation and building cultures in communities and
nations that respect human rights. Only with these in place can health be truly
attained.
Ife and Tesoriero (2006) argue that engaging in development at the community level
should necessarily entail human rights work. This is because, despite the many
Declarations of human rights, the voices of the marginalised are so often not heard.
Human rights, including the right to health, continue to be violated. Therefore, health
and development work must be about a process of building a culture of human rights,
establishing the conditions which enable human rights to be respected and which
enable people to assert and obtain their right to health. This current school of thought
is fully consistent with some traditions in health, including comprehensive primary
health care. It also brings together the three fields of health, development and human
rights. It (as does the social view of health) challenges each of these as ‘silos’, not
needing to be in relationship with each other.
Comprehensive Primary Health Care emerged from Alma Ata as an approach to
health to address the growing disparities in health status and to address the
worsening health status of the poor around the world. Accordingly, its core principles
relate directly to the political and social factors which were considered as
perpetuating low health status. Equity acknowledged the disadvantages of poor
people and the need to redress inequalities. Health Promotion/Illness Prevention
ensured an ‘upstream’ approach whereby illness could be prevented and
communities could be strengthened to promote the right of health of their members.
Intersectoral collaboration, the cooperation amongst organisations both within and
outside the health sector, was seen as an essential element because health was not
38. 34
just medical, but was determined by factors outside the health sector and so required
the involvement of those sectors, such as education, housing, welfare, economic
development agencies and so on.
Poor people are mostly marginalised from power and other resources necessary for
health. Consequently participation was an important principle in comprehensive
primary health care. Both as a means and an ends, participation aimed to enable
poor people to engage in decision making about their own health strategies. Related
to the principle of participation, the notion of local control, that is, the control of
health services in the hands of people in local communities, rather than at a
centralised bureaucratic level, was an important principle to enable participation to
have decision making power and for health services to be shaped in ways that were
relevant to local conditions. To further reinforce the urgent need for health services to
reach the poor, comprehensive primary health care also encompassed the principles
of accessibility, affordability and acceptability by local communities.
The Health Debate Journey to 2006
As is evident in the World Health Organisation’s definition of health, the organisation
clearly saw the need to address the social contributors to ill health and its paradigm
was greater than a narrow medical view of health. However, during the 1950s the
focus of public health and the preferred model of health was one based on high
technology and campaigns aimed at specific diseases. Successes in drug research
spurred a belief in technology as the answer to health problems; and this belief was
strongly bolstered by the burgeoning pharmaceutical industry. Colonisation also
affected health care systems in the developing world as they were western medical
systems provided by the colonisers and mainly to meet the needs of the elites from
the colonising nations and within the elites within the colonised nations. Most health
campaigns were vertical in nature, targeting specific diseases and appearing to be
highly efficient and effective. In the narrow sense, many of them were just that.
Malaria was a notable exception and a costly failure at the time. However, almost
without exception, all the seemingly effective campaigns ignored the social context,
including poverty, leaving these issues unaddressed and so perpetuating inequalities
As the 1970s were approaching, awareness grew about the inadequacies of a
technological, western medical (and narrowly educative) approach which ignored
social factors and community ownership in the health venture. Halfdan Mahler, who
became Director General of World Health Organisation in 1973 was both charismatic
and a passionate believer in social justice in health. Mahler’s “Health for All by the
year 2000”, he asserted “implies the removal of the obstacles to health – that is to
say, the elimination of malnutrition, ignorance, contaminated drinking water and
unhygienic housing – quite as much as it does the solution of purely medical
problems”. (Mahler 1981, p5)
Soon after the Declaration of Alma Ata by the World Health Organisation in 1978,
neoliberal economic policies swept across much of the western world. This
movement resulted in government policies which privileged an economic view of the
world, a minimal role for the state and a view of the world as a market place where
commodities, including health, could be bought and sold. Economic globalisation
processes further shaped and strengthened the power of worldwide economic power
brokers, most notably multinational corporations. Policies of economic liberalisation
and privatisation were progressively adopted by almost all states across the globe.
39. 35
The solution to the debt of poor countries was framed by the structural adjustment
policies whereby assistance from the World Bank with poor countries’ debt
repayment of was conditional on their willingness to adjust their economies to be
more productive contributors to the global markets. They were pressured to reduce
expenditure on what were considered economically non productive areas, such as
health and education, and to accordingly adopt a user pay system to fund these
areas.
The impact of economic globalisation is captured graphically in the following
description:
“‘Globalisation’ refers to the emergence of a global economy
characterised by market forces and the prominence of economic actors
such as transnational corporations, international banks and other
financial institutions… Globalisation is marked, especially, by the growing
power of international agencies of capital – notably the World Trade
Organization (WTO), the World Bank, the International Monetary Fund
(IMF) and the World Economic Forum (WEF).
Globalisation is also characterised by increasing socio-economic
polarisation (with and between nation-states) and decreased political
choice for citizens, because virtually all major parties across the world
have committed themselves to globalisation. With hi-tech
communications, lower transport costs and unrestricted trade turning the
whole world into a single market, fierce global competition encourages
‘downward adaptation’ within each state towards lower wages and
working conditions for most employees, decreased public spending on
social services, and increased subsidies and tax-breaks to transnational
corporations.” (Bergman 2003, p2)
Within this context, which was increasingly dismissive of, and hostile to, the
promotion of human rights, the concept of comprehensive primary health care was
contested and seen as too idealistic and too costly for governments with shrinking
resources. The alternative, selective primary health care, was proposed. This
approach entailed targeting specific diseases and introducing particular technologies
to address illness. The initiative for decisions about what diseases would be targeted
and the ownership of the technologies were external to communities, and imposed
from on top. While proponents of selective primary health care held the view that it
was a realistic compromise of comprehensive primary health care, others argued it
was a positive undermining of the approach because it negated and eroded
important principles such as participation, local control and so on.
It is significant that during this period several countries in the developing world were
still able to become showcases of good health practice. These included Costa Rica,
China, Sri Lanka, Cuba and Kerala in India. These became known as the GHLC
(good health at low cost) cases and are still cited today as cases of progressive
health and development approaches which include non health sectors in improving
health status.
Rosenfield (1985) analysed the GHLC cases and discerned five factors that they had
in common and which were significant in the successes in these countries. These
factors were
An historical commitment to health as a social goal.
A social welfare and well being orientation to development.
Community participation in decision making processes in health.
A commitment to equity through systems of universal access to health care.
40. 36
Intersectoral collaboration for health.
The successes of the GHLC countries, combined with the analysis of the important
social and political factors, spawned both encouragement and the realisation of the
paucity of countries having the social and political conditions conducive to success.
Criticisms about the lack of measurability of a social approach to health in a growing
climate of neoliberalism and managerialism did not auger well for a broad
comprehensive approach to health; and so represented another and significant
obstacle to implementation of comprehensive primary health care.
Throughout this period of neoliberal policies and in the globalised world, health
organisations and health activists have continued to advocate approaches which are
underpinned by health as a human right. This health movement can be seen as a
part of a larger movement challenging the dominance of economic discourses. The
World Social Forum is perhaps the starkest illustration of this global movement
against economic dominance. The protests against the G-8 in Seattle, Melbourne,
Genoa and other places were protests against the dominance of globalised capital in
the hands of multinational corporations. The People’s Health Movement, the People’s
Charter for Health and the two People’s Health Assemblies held in Bangladesh and
Ecuador respectively, have advocated for health as a human right and have
encompassed a wide range and large number of poor people’s health movements
from around the world.
The erosion of the primary health care discourse, yet the continuing struggle by its
champions, was attested to when, in 2000, over fifteen years of planning by health
activists across the globe culminated in the People’s Health Assembly in Savar,
Dhaka, Bangladesh. At this Assembly, over 1,500 people from 93 countries re-
asserted the Alma Ata Declaration and developed the People’s Charter for Health to
advocate for policies which give priority to health and well-being, to equity, peace and
ecological sustainability (People’s Health Assembly 2000) in a context where
economic imperatives are the major forces behind policy.
The People’s Charter for Health, endorsed at the Assembly, states:
“Health is a social, economic and political issue and above all a
fundamental human right. Inequality, poverty, exploitation, violence and
injustice are at the root of ill-health and the deaths of poor and
marginalised people. Health for all means that powerful interests have to
be challenged, that globalisation has to be opposed, and that political and
economic priorities have to be drastically changed.” (People’s Health
Assembly, 2000)
In January 2004, the third International Forum for the Defence of the People’s Health
at Mumbai reaffirmed the relevance and validity of the People’s Charter for Health
(People’s Health Movement 2004) and insisted on action by the People’s Health
Movement, civil society and governments to build peace, engage in political
advocacy to challenge neoliberalism and to implement comprehensive primary health
care. The second People’s Health Assembly, held in Cuenca, Ecuador, in July 2005,
maintained and further strengthened the world-wide people’s movement for the right
to health for all.
Also during the 1990s and early 2000s some countries made notable strides in their
efforts to address social determinants of health. These efforts can be traced back to
41. 37
such landmark reports as the Lalonde Report (1974) in Canada and UK Black Report
(1980).
Leading health activists and theoreticians were also continuing to advance broad
perspectives on health. Labonte (1992) in Canada developed the socioenvironmental
approach to health promotion. This approach was fully consistent with a social view
of health and reflected a strong appreciation of health as a social and political issue.
The approach consists of three layers or dimensions. The first is the medical or high
risk approach; the second, somewhat broader but still focused on the individual, is
the behavioural approach; and the third, much wider perspective is the
socioenvironmental view.
The medical or high risk perspective has a focus on individuals with unhealthy
lifestyles and health is defined as illness, absence of disease, and disability,
diagnosed by medical experts. The health problem is defined as disease categories
and physiological risk factors (medical definition). Strategies include illness care,
screening, immunisation and medically-managed behaviour change. Success
criteria centre on decreases in morbidity and mortality and decreases in physiological
risk factors.
The behavioural approach has a focus on individuals and groups. Health is defined
as individual practice of healthy behaviours (lifestyle oriented). The problem is
defined as behavioural risk factors and is defined by experts. Strategies to address
behavioural issues include mass media behaviour change campaigns, social
marketing and advocacy for policies to control harmful agents. Success criteria are
behaviour change, decline in risk factors for disease.
The socioenvironmental approach includes the high-risk and behavioural, but
encompasses much more than either or both of these. Within the broader
socioenvironmental approach, the focus is on communities and living conditions,
rather than individuals or groups. Health is defined as strong personal and
community relationships; feelings of ability to achieve goals and be in control. The
health problem is defined in terms of socio-environmental risk and psychosocial risks.
Equity is a key factor. Community involvement in the problem definition is an
important feature. Strategies involve community development: encouraging
community organisation, action and empowerment; political action and advocacy.
Success is measured in terms of individuals who have more control, social networks
that are stronger, collective action for health which is evident, and a decrease in
inequalities between population groups
The World Health Organisation’s healthy settings approach to health also represents
an adherence to principles of primary health care and a social view of health. This
approach includes such programs as the World Health Organisation’s Healthy Cities,
Health promoting Schools, Health promoting workplaces, Health promoting hospitals
and so on. Most recently has been the development of the Healthy Districts approach
in the South East Asia region as a rural version of Healthy Cities.
Health and development are closely related and the concept of participatory
development is relevant to a healthy settings approach and in particular, to the
healthy districts approach. Baum identifies the main features of healthy settings,
which include the following:
based on an appreciation of the importance of multidisciplinary and
cross-sector working
42. 38
Have a health promotion focus that recognises that environmental
and structural factors have a greater impact on health than
behaviour…The focus on action is on policy, organisations and
communities rather than individuals
Recognise that organisational and community development are key
strategies to being about change” (Baum 2005, p475)
Participatory development means health and development programs that include the
participation of local people and community-based groups, as well as health and
other professionals. This is a central concept in health development and primary
health care because it maximizes the chance of effective and long-lasting health
outcomes and health gains.
Participatory development is critical to a Healthy Districts Program because it
encourages collaboration by its emphasis on wide inclusion of all groups and
stakeholders, both those with expert knowledge and those who are affected by
Healthy Districts programs and activities.
There are several well accepted benefits of participatory development as a guiding
concept and these can be applied to a Healthy Districts program. These benefits
are:
Coverage: by increasing the number of groups and people participating in
processes, the number of beneficiaries is also increased.
Efficiency: resources are more efficiently used because better and wider
collaboration is promoted.
Effectiveness: goals and strategies are more relevant to local health needs
when local views are included in decision-making and planning.
Equity: wide participation of different groups in a District helps promote benefits
for those most disadvantaged in a District.
Participatory development means that value has to be given to the processes in a
Healthy Districts program, as well as to outcomes. If this is not so, then either the
program will have little or no participation, or the participation will be tokenistic. In
either case, there is the danger of lowering sustainability and increasing local
cynicism to the goals and strategies of a Healthy Districts program. It is important
that participatory development is not used merely to get acceptance for pre-
determined services, but that it is a valued resource and an integral concept in
Healthy Districts programs for finding new and creative solutions to health issues in a
District.
Participatory development requires a suitable political context of decentralised
decision-making and so a Healthy Districts approach and participatory development
are well suited to each other. Healthy Districts represents a health planning
approach which emphasizes the appropriateness, relevance, acceptability and
accessibility of resources to all groups within a District through greater collaboration,
rather than only treating disease by medical technology. The Healthy Districts
approach to promoting health is therefore supportive of participatory development.
Participatory development has implications for activities in Healthy Districts
programs: both the encouragement of staff and organisations to include local
people’s input and knowledge; and the facilitation of local people and groups, to
ensure they have the resources, skills and knowledge to effectively and confidently
participate.
43. 39
Healthy Districts in South East Asia
In the late 1980s-early 1990s, a number of Healthy City projects were initiated in
industrialised countries mainly in Europe and North America. In the 1990s the
approach spread to other regions of the world including the WHO South-East Asian
Region. Healthy Cities projects were commenced in Thailand, Nepal and
Bangladesh. The cities in which these projects were developed differed considerably
in size from, for example a metropolitan wide project in a mega city such as Bangkok
(following piloting in specific districts) to projects in cities in Bangladesh (Chttitagong)
to a project in the Municipality of Banepa in Nepal.
The World Health Organisation South East Asian Regional Office (WHO SEARO)
has also encouraged the development of a number of other healthy settings
approaches. A specific meeting was held in relation to healthy hospital in late 2000
(World Health Organisation 2000a) which reported on processes towards shifting
hospitals from an entirely curative approach to one emphasising comprehensive
health care including promotive and protective services. Other healthy settings
approaches have been developed within the umbrella of Healthy Cities projects.
These include healthy markets, healthy schools and healthy workplace initiatives.
The regional support for healthy settings approaches was formally acknowledged
and recognised in 2000 as shown by a resolution resulting from a regional meeting.
This regional Resolution (World Health Organisation 2000b) urged Members States
to:
“to identify by the end of 2001, at least one district to pilot a “healthy
setting” programme, with active involvement of local communities, other
sectors and NGOs to evaluate the existing technical and managerial
capabilities for promoting various “healthy settings” programmes, and
enhance these where necessary.”
The same resolution also called on the Regional Director:
“(a) to provide necessary technical support, including guidelines and
indicators to Member States for formulating plans to establish “Healthy
District” initiatives.” (WHO Regional Committee for South East Asia 2000
(SEA/RC/R4) Resolution)
These guidelines were prepared by Professor Fran Baum and Dr Frank Tesoriero for
the World Health Organisation (SEARO) in 2001. The rationale for the Healthy
Districts approach is contained in the report and documentation of the WHO
(SEARO) technical discussions held in New Delhi 31 August, 2000, which were in
conjunction with the 37th meeting of CCPDM (World Health Organisation 2000c).
A review of the healthy settings (health promoting schools, healthy cities, health
promoting hospitals, model village and thematic healthy settings) across the SEARO
countries identified a number of challenges facing the healthy settings approach
which, if addressed, could build on the positive achievements of healthy settings
initiatives and also address their failures and inefficiencies, thus enabling the
improvement and expansion of the healthy settings program. These challenges
were:
44. 40
1. Political commitment at the local level is low in a few countries and
this manifests in a lack of leadership at the local level, poor
intersectoral collaboration and integrated planning and implementation
at the local level.
2. The lack of involvement of NGOs, agencies and community leaders
and of partnerships amongst all key players.
3. Lack of mechanisms to balance local and national priorities and
negotiate between these as decentralisation enables greater local
participation in policy and planning.
4. Lack of linkages between healthy settings activities that are
community-based (focussing on particular sections of the population)
and those that are thematic-driven (health issue-oriented)
These findings of the review have led to an awareness of the need to adopt a
comprehensive health system where most challenges were identified – the local
level. It is the district health system which is administered at the most local level and
generally parallels physical and political environments that are manageable.
The Healthy Districts approach, then, adds value to the healthy setting approach.
The Healthy Districts approach strengthens healthy settings’ ability to manage
initiatives collaboratively across sectors and build an infrastructure over a range of
settings, which is able to capitalise on and optimise the benefits that derive from the
healthy settings approach and address the local level deficiencies in settings.
The Healthy Districts approach also assists in moving local health systems towards a
situation in which the health service can put more emphasis on health promotion.
In most countries District Health Systems (DHS) are the local organisational
structures which are responsible for implementing comprehensive primary health
care. ‘District’ is used in a generic sense to denote a clearly defined administrative
area, which commonly has a population of between 50,000 and 500,000, where
some form of local government or administration takes over many of the
responsibilities from central government sectors or departments, and where a
general hospital for referral support usually exists. The actual organisation of district
health systems obviously depends on the specific situation in each country and each
district, including the political and administrative structure and local history.
In 1986, the WHO Global Program Committee described the District Health System
in these terms:
“It comprises first and foremost a well-defined population, living within a
clearly delineated administrative and geographical area, whether urban or
rural. It includes all institutions and individuals providing health care in the
districts, whether governmental, social security, non-governmental,
private or traditional. A district health system, therefore, consists of a
large variety of interrelated elements that contribute to health in homes,
schools, work places, and communities, through the health and other
related sectors. It includes self-care and all health care workers and
facilities, up to and including the hospital at the first referral level and the
appropriate laboratory, other diagnostic, and logistic support services. Its
component elements need to be well coordinated by an officer assigned
45. 41
to this function in order to draw together all these elements and
institutions into a fully comprehensive range of promotive, preventive,
curative and rehabilitative health activities.”
‘District’ can cover any local or regional health system and the organisations that are
part of that system (Laris et al 2001). In India, such systems exist at both the
administrative/political levels of District and Block. The district is widely used as a
convenient and generally acceptable unit through which to organise the integrated
delivery of primary health care services and health promotion initiatives. A district is
most usually a more or less self-contained part of a national health system. As such,
it is likely to be a fairly clearly identified administrative, demographic and/or regional
entity. This gives people reasonable and manageable local and regional boundaries
within which to operate and where they are likely to have most influence and
opportunities to promote health. The District is a good unit from which to develop
alliances with civil society organisation.
“A Healthy Districts is one that is continually creating and improving those
physical and social environments and expanding those community
resources which enable people to mutually support each other in
performing all the functions of life and in developing to their maximum
potential.” (Hancock 1988)
Thus a Healthy Districts Project focuses on creating a healthier population through
improving the physical and social environment and providing supports which enable
people to live healthy lives. A district could be described as a Healthy District if it can
commit to the development and maintenance of physical and social environments
that support and promote better health and quality of life for members of the
community. Building health considerations into the overall development and
management decisions made in all sectors within the district is crucial for a Healthy
District. In other words, a Healthy Districts approach builds a healthy district by
focusing on the conditions that influence health, rather than on the state of health per
se.
Key features of a Healthy Districts initiative includes: high political commitment;
intersectoral collaboration; community participation; integration of activities in
elemental settings; development of a district health profile and a local action plan;
periodic monitoring and evaluation; participatory research and analyses; information
sharing; involvement of the media; incorporation of views from all groups within the
community; mechanisms for sustainability; linkage with community development and
human development; and national and international networking.
Healthy Districts initiatives have the potential to encourage local governments to
engage in health issues, to promote innovation and change in local health policy and
to advocate for new approaches to public health.
The potential of Healthy Districts, namely the implementation of the approach at the
district level, has been inconsistent and sparse, due mainly to the effects of
neoliberal policies which tend to reduce people to individual consumers, thus
backgrounding the structural and social determinants of health in favour of more
individualistic accounts, such as individual behaviour, for varying health and illness.
This is in spite of much evidence on the social determinants of health (McGinnis et al
2000; Tarlov 1996; Shiva 2000; Asthana 1994; Boyce 2001). As Marmot asserts
46. 42
“The gross inequalities in health that we see within and between
countries present a challenge to the world. That there should be a spread
of life expectancy of 48 years among countries and 20 years or more
within countries is not inevitable. A burgeoning volume of research
identifies social factors at the root of much of these inequalities in health.”
(Marmot 2005, p1099).
If evidence abounds, political will in the contemporary political and economic context
has been clearly lacking. However, we are witnessing a reinvigorated attempt to
apply the knowledge of social determinants of health to policies and programs
through the recently established World Health Organisation’s Commission on the
Social Determinants of Health. That the World Health Organisation has given this
group the status of a Commission is itself noteworthy.
Social Determinants of Health
Healthy Districts is clearly founded on a view of health being determined by social
and structural determinants. It attempts to effect environmental and structural
changes at the local and district level.
The action research approach which is at the core of this Healthy Districts Project
and is its prime methodology, represents excellence in health work and development
work. Furthermore, it has special significance within the neoliberal paradigm, of
which India is now tightly enmeshed. Healthy Districts represents a challenge to
neoliberal discourses and as such it is clearly a political approach to health.
This political dimension of health has been recognised by the establishment, in 2005,
of the World Health Organisation’s Commission on Social Determinants of Health.
The Commission is in recognition of the substantial evidence linking structural factors
to health status and the substantial lack of application of this evidence to policy and
practice.
“The Commission will work with countries to mainstream and strengthen
actions to address the social determinants of health inequities…The
scope of country actions will range from: (a) strengthening interest in
social determinants and developing a common vision and understanding
of priorities among stakeholders; to (b) adapting, scaling up and
mainstreaming existing circumscribed programmes, which have a proven
positive impact on the social determinants of health inequities; to (c)
implementing comprehensive reforms to frame health as a corporate
priority in public policies and intersectoral action.” (Commission on Social
Determinants of Health, 2005b, p3)
The Commission reflects a current optimism about advances in health policy which
address the social determinants of health. This optimism comes from several factors
which are at play, namely:
47. 43
The scientific evidence base of social determinants of health.
The rise and mobilisation of significant constituencies, such as the People’s
Health Movement and the World Social Forum;
The broadening of the concept of development beyond economic development
to human development, and embracing human rights. (Commission on Social
Determinants of Health, 2005a, p38)
But not all countries and all communities are included in the application of evidence
and the outcomes of social movements. The Commission sees its work as taking
this momentum to the next level by several means:
Brokering a wider understanding and acceptance of the social determinants
among decision makers and other stakeholders, particularly in developing
countries.
Translating knowledge into policy agenda appropriate to the local conditions of
different countries.
Identifying and demonstrating the scaling up of successful interventions.
Embedding social determinants in approaches by the World Health
Organisation and other global actors in health. (Commission on Social
Determinants of Health, 2005a, p38)
The Healthy Districts Project represents a contribution to the third of these four
strategies of the Commission.
How change in health status is promoted can be represented along a continuum and
the entry point for policy and program action can be mapped accordingly. If health is
socially determined and health and illness are thus socially produced, there are
several entry points along the chain of production, namely:
“Decreasing social stratification itself, by reducing “inequalities in power,
prestige, income and wealth linked to different socioeconomic positions”;
Decreasing the specific exposure to health-damaging factors suffered by
people in disadvantaged positions;
Lessening the vulnerability of disadvantaged people to the health-damaging
conditions they face;
Intervening through healthcare to reduce the unequal consequences of ill-
health and prevent further socio-economic degradation among disadvantaged
people who become ill. “(Commission on Social Determinants of Health,
2005a, p40)
This Healthy Districts Project aims, at the local level, to intervene at the first point of
the social production of health and illness by working with members of local
communities to reach their aspirations to make durable changes to their
socioeconomic conditions and those of their children and future generations. As a
pilot project, it has potential to ‘scale up” (Uvin, Jain and Brown 2000)and for its
reach to be beyond the local level to be applied in other local sites and to
demonstrate an approach that can be adopted at a District-wide level.
48. 44
Health, Development and Human Rights Discourses
This discussion points to the interrelationships between the Healthy Districts
Approach and important traditions and perspectives in public health. Of these, the
most notable are those which emphasize the social and economic dimensions of
health.
The social determinants of health have been further highlighted by the UN Millennium
Project. This project and its final report reinforce the interrelatedness of many health,
economic, social and environmental issues which have an impact on development.
Interrelated issues require interrelatedness in strategies and solutions – coordinated
and intersectoral collaboration. The ideas of intersectoral collaboration and
community participation in health planning form central planks in any approaches to
health development activity (see Shaw and Martin 2000; Roussos and Fawcett 2000;
Delaney 1994; Ashman 2001; Babacan and Gopalkrishnan 2001; Mosse 2001; Teck
et al 2001; Weinberger and Jutting 2001). This again is a central plank in the Healthy
Districts approach. The Millennium Development Goals (MDGs) underscore the
interdependence of health, social and economic factors. Targets for poverty
reduction, hunger reduction, education, women’s empowerment, environmental
sustainability and global partnerships for development are closely intertwined with
health issues.
The contemporary global agenda for development is clearly being shaped by the
MDGs. However, the extent to which these goals are consistent with human rights is
a contested and debated area. Most radically, Pogge (2003) argues that Goal One is
Panchayat
(local)
Panchayat
(local)
Panchayat
(local)
Panchayat
(local)
Panchayat
(local)
Panchayat
(local)
District
Level
Healthy
Districts
Project
Healthy Districts Project at the local level, ‘scaling up’ by extending its reach across other local sites
in a district and up to the district level
49. 45
a crime against humanity on a large scale because it allows half of today's poor to
continue to live in a state of poverty and deprivation.
Regardless of where one positions oneself in relation to Pogge’s claim, a critical
issue which cannot be ignored lies behind it. That issue is the perpetuation of
poverty. Despite many sustained efforts to reduce poverty in India, about 30% of
India’s population continue to live in extreme poverty. About 80% of these people
live in rural India and many of these are coolie workers in the currently ailing
agricultural industry (Chandrasekhar 2006). Access to economic resources is a
major issue and women have been especially marginalised in this respect (Purao
2000). The outcomes of development and poverty alleviation programs have not
matched expectations (Kumara, 2001) and analyses indicate that central planning
may be far less effective than local planning and intervention which is possible
through NGOs (Ramsamy and Shanmugam 1992). This is thought to be largely
because of their ability to be more flexible and responsive (Srivastava 1999). NGOs
are more likely to be able to empower local communities through skill development,
building local organisations and capacity and participatory processes and
approaches (Suguna 2001). The Healthy Districts approach provides a means for
working from an empowerment, participatory and capacity building base, using local
organisations which are able to be responsive to and flexible for local needs and
conditions.
The perpetuation of extreme poverty is perhaps the major human rights issue of our
time. The MDG program brings with it a hope that this may be the best chance so far
to effectively address poverty. In this sense, the MDGs have potential human rights
implications. According to Alston (2005), however, the MDG community and the
human rights community have so far been like ships passing in the night, with no real
engagement with each other. He claims that any approach to development which
ignores human rights altogether or treats them solely in a token fashion, neglects a
crucial dimension of the development equation and overlooks the empowerment
potential of rights. It also gives little incentive for the human rights community to
engage in the MDG process and fuels arguments for incompatibility between the two.
Other theorists, however, are advocating the inseparability of human rights and
development. Uvin (2004) argues this when he states that
“there is no way to separate human rights from economic and social
improvement; the terms mean nothing without each other and can only
become meaningful if ey are redefined in an integrated manner. Maslow
is dead; there are no basic needs…the process by which development
aims are achieved is as important as the actual products. Processes can
build on, strengthen, neglect of undermine local capacities, local
networks, local knowledge and ways of generating it; they can also fail to
respect people and their dignity or their cultures. In that case, the aid
given further reinforces the state of deprivation, even though more
calories may temporarily be available.” (Uvin 2004, p123)
Approaches which encompass and attempt to address social determinants of health
provide one mechanism whereby human rights and development can come together.
Acknowledgement of social determinants of health does two things: on the one hand,
the focus is on the rights of people to live in safe and secure conditions rather than
focusing only on individual, ‘deficient’ behaviour; and on the other hand, addressing
social factors as determinants of health status brings together health (as a human
right) and development, thus maximising the opportunities for intersectoral
