2. com h org and dev unit 2

Unit 2: Community Health Development
Draft version 5
Upendra Raj Dhakal
(16 hrs)
Lecturer: Valley College of Technical Science, Kathmandu

Concept
Community Health Development: Draft Version 5 (Feedback
Welcomed)
2

Concept
• Development covers: food, shelter, resources, technology, economic and
political security.
• Respect and preservation of cultural heritage, values and norms,
• Favorable social, physical and biological environment
• The positive change, progress or improvement of different aspects of the
community is called community development.
• Community development is a democratic process in which the people
participate to improve their all aspects of development by themselves.
• It aims in overall development in the field of: agriculture, animal
husbandry, irrigation, education, public health, rural industries, cottage
industries, communication, etc..
Welcomed)
3

Definition
The process in which people of the community get involved in
identifying needs, planning, implementing, using local
resources, monitoring and evaluating for improvement of
economical, social, cultural, health status and other related
aspects of community.
The co-operation and participation will be taken from the
community and government for above activities.
Welcomed)
4

Types (Also refer unit 1)
• Development of health in Rural community: ……
• Development of health in Urban Community: ………..
• Development of health in Semi urban community: …………
It can also be described longitudinally (history) as:
• CHD as a process
• CHD as a program
• CHD as a method, and
• CHD as a movement
Welcomed)
5

Goal
• Improvement in the financial condition of the community
• Promotion of democratic feelings in the community
• Creation of social awareness in the community
(Prof. Dr. Y.P. Pradhnanga)
• Identify and solve health problems
• Analyze the health problem and increase the health status
• Increase the positive health behavior
• Utilizing human resources for physical development
Welcomed)
6

Features of theories of CD
• Community development theory recognizes that maintaining roles, structures and
processes which are performing well is vital.
• The working the community system has a dual structure. One side is designed for
stability, for regular performance, and for predictability. The other side of the system is
designed for evaluation and change.
• Community development theory accepts the proposition of classical conservatism that
the cumulative opinions and rules of communal life are to be respected.
• Community development theory suggests a balanced respect for the potency of both
tradition and social invention.
• Community development theory proposes that it is far more likely for the system to
overweight the conservative side.
• Community development theory advocates that in addition, community system should
allow an equality of standing for citizen roles.
• Community development theory does not present total participation as the ideal which
results from the freedom of people to decide for them.
https://www.academia.edu/2564568/Community_Development_Theory
Welcomed)
7

Principle of Community Development - 1
• Community Participation
• Community ownership
• Empowerment
• Lifelong learning
• Inclusion
• Access and Equity
• Social Action
• Advocacy/Activism
• Networking
• Self Help
Welcomed)
8

Principle of CD - 2
• Democratic
• Inclusive
• Non – authoritarian
• Community Self Determination
• Community Ownership
• Enhance natural capacities and networks
• Social justice and equity
• Universality
• Service Integration
• Upstream
(http://www.ohcc-ccso.ca/en/courses/community-development-for-health-
promoters/module-one-concepts-values-and-principles/values- )
Welcomed)
9

Principle of CD (Michael and Julie Bopp) – 3
• Harnessing Community Tensions: ……….
• Facilitating Consultation about Community Realities and Needs: ………
• Maintaining Unity and Healthy Human Relations: ……….
• Developing a Common Vision of Sustainable Future: ……..
• Supporting Core Group Development: ……….
• Personal Revitalization and Healing: ………
• Facilitating Learning: ………..
• Building Effective Organizations: ………….
• Networking with Resources and Allies: …………..
• Programme Development: ………….
• Reflection on the Process: (Monitoring and Evaluation): ……………
• Protecting the Process: …………….
(http://www.agriinfo.in/default.aspx?page=topic&superid=7&topicid=1456)
Welcomed)
10

10 steps of community development
• Learn about the community
• Listen to community members
• Bring people together to develop a shared vision
• Assess community assets and resources, needs and issues
• Help community members to recognize and articulate areas of concern and
their causes
• Establish a ‘vehicle for change’
• Development an action plan
• Implement action plan
• Evaluate results of actions
• Reflect and regroup
Welcomed)
11

Community Development Strategies
• Local Development
• Social Action
• Social Planning
• Social Reform
• Community Relations
• Social Capital Formation
• Capacity Building
• Asset – Based Community Development
(http://www.ohcc-ccso.ca/en/book/export/html/380)
Welcomed)
12

Community Empowerment
• A process that respects, values and enhances people’s ability to have
control over their lives is put into practice.
• This process encourages people to meet their needs and aspirations
in a self-aware and informed way which takes advantage of their
skills, experience and potential.
• Change and growth occurs through informing and empowering
individuals and communities.
Welcomed)
13

Contd …
• Community empowerment is more than the involvement,
participation or engagement of communities, but also community
ownership and action that explicitly aims at social and political
change.
• Community empowerment is a process of re-negotiating power in
order to gain more control.
• Community empowerment necessarily addresses the social, cultural,
political and economic determinants that underpin health, and seeks
to build partnerships with other sectors in finding solutions
Welcomed)
14

Process of Community Empowerment
4. Social Mapping
5. Community Organizing
6. Planning
7.
Implementation
8. Beneficiaries
1. Socialization in the communities
2. Community meeting
3. Poverty Reflections
Welcomed)
15

Stages of community empowerment
• The discovery Stage: People discover they are not alone. Identify critical character as source of
connection with like minded people.
• The Partnership-Creating Stage: Search for collaboration with common interest.
• The Self – Definition Stage: Identify their own situation. It is also a stage of discovery.
• The Self – Representation Stage: Ability of individual to exemplify themselves by increased self
confidence.
• The Stage of Resistance to Existing Policy: Resist others definition and define themselves. People
either reject the policy as a whole if it does not suit them, or plan to change particular programs
in policy.
• The Stage of Presenting an Independent Alternative: People who represent themselves as a
resistant give alternatives to the proposals affecting their community. People conclude by “Either
you plan or they plan for you.”
• The Evaluation Stage: People evaluate their achievements and rediscover the limits of their
empowerment.
(Elisheva_sadan_empowerment_Chapter6.pdf)
Welcomed)
16

Different Aspects of CHD
• Economic: ED is a part of CD. It involves many elements of community
development, such as participation, rethinking, action learning, etc.. –
however the main aim is to improve the relative economy, ….
• Political: Political stability and bills. Democratic decisions, insurance and
tax, restructuring the boundaries and rights, privatizations,
consumers/customers choice, …
• Social: Fragmentation and small group representatives, inequalities,
increase in competitiveness, infrastructure development, inclusion,
development of social scales for measurements, social capital, socio –
cultural, ….
• Legal: Laws and acts, World bank 2012:ix (CDA), Industrial acts, consumers
act, Rewards, Penalties and Punishment, Community lawyering, Ethical
issues, ….
Welcomed)
17

Development and Community Health
• History of Public Health ….and PHC …. (In Nepal) – will be done at last
• Concept of equality and equity ….
• Community led approach ….
Welcomed)
18

Equity and Equality
• Equity: Fairness or Justice in the way people are treated. It involve trying to
understand and give people what they need, even if it is not equal. It is a
principle of fairness.
• Equality: The quality or state of being equal; the quality or state of having
the same rights, social state, etc... It is ensuring individuals and
communities are offered the same opportunity and treated no less
favorably. It is a principle of sameness.
• Fairness: Fairness can be in the form of equity or equality. There is always a
debate as defining equity and fairness as same or different. Fairness is a
quality of having an unbiased disposition, without discrimination or
partiality. It is the absence of prejudice (partiality).
Equity is the process; equality is the outcome
Welcomed)
19

Equity, Equality and
Fairness
(1 Vs 2 Vs 3)
Welcomed)
20

Community Led Approach
• It is one approach of community empowerment
• Broader engagement of community occurs.
• Community identifies issues and generate local solutions
• Though ignition might be done extraneously, its further development, saturation
and sustainability is owned by community.
• Community-led Development (CLD) is the process of working together to create
and achieve locally owned visions and goals.
• It is a planning and development approach that’s based on a set of core
principles that (at a minimum) set vision and priorities by the people who live in
that geographic community, put local voices in the lead, build on local strengths
(rather than focus on problems), collaborate across sectors, is intentional and
adaptable, and works to achieve systemic change rather than short-term
projects. (http://inspiringcommunities.org.nz/resources/about-cld/principles/)
Welcomed)
21

Principles of Community Led Development.
• Shared local visions or goals drive action and change.
• Use existing strengths and assets.
• Many people and groups working together.
• Building diverse and collaborative local leadership.
• Adaptable planning and action informed by outcomes.
(https://www.communitymatters.govt.nz/community-led-development-principles/)
Welcomed)
22

Development and Community Health
Community
• Group Dynamics
• Community Diagnosis/Survey
• Community Organization
• Community Empowerment
Aspects
• Economic Development:
• Political Development:
• Social Development:
• Legal Development:
• …………:
(See previous slides)
Nature should not be destroyed in the name of development.
Welcomed)
23

Development and Community Health …
Welcomed)
24

Cross Cutting Issues
• Unstable Politics: …….
• Health politics: ………….
• Disaster (Natural/manmade)
risk reduction: ….
• ESI and sexual violence:
……(GESI)
• Crime and Terrorism: ………
• Human Rights and justice: ……
• Disabilities and justice: ….
• Child Participation: ….
• Environmental impacts and funding: ….
• Public involvement and ownership: ….
• Knowledge management and Practice:
….
• Religion and culture: ….
• Stigma (shame) and discrimination: …..
• WASH: ….
• Corruption:
• Urbanization (shortage of food ….)
Welcomed)
25

Techniques of CD and their application
• External Agent Technique
• Multiple Agent Technique
• Internal Resource Mobilization Technique
Welcomed)
26

External Agent Technique
• The appointment of an external agent for the development of community
program is the best approach.
• One convinces the people through the personal skills and experience and
motivate them to work for the development of community.
• One identifies various problems and seek suitable solutions for it.
• One organizes the people discuss the situation, arrange meetings, forms
committee and village councils to highlight the hinders in the
developmental procedures.
• At last person presents a policy for the community and the whole society
adopt it for development.
• The external agent approach is also called managerial approach.
Welcomed)
27

Multiple Approaches
• In this approach some members are selected from the whole community.
• They try to make a combined policy for the improvement and betterment of the
people.
• In this approach the community development experts try to provide various
facilities including health, education, sanitation, recreation etc. to control the
causative factors in the way of community development.
• The basic philosophy of multiple approaches is to convert centuries into decades.
• The adaptation process must be kept in mind and the values, traditions, beliefs,
and norms should be care.
• Slowly and gradually development must be given to the community.
• This approach is also called Representative approach because these people work
in community as representatives of the whole locality.
Welcomed)
28

Inner Resource Approach
• In this approach the local people are encouraged and motivated to use
their resources for the improvement of the areas.
• These people are guided by the representatives of the community through
various programs working internally.
• They arrange meetings discussions, give suggestions and agreements in the
community. So, the people should motivate to improve the living standard
of the whole community by using their internal resources.
• This inner approach of community development is also called participatory
approach because the people actually take part in the progress and
promotion process.
• This participation of the members is to utilize their skill and knowledge for
the betterment of community.
Welcomed)
29

Citizen Charter
• Citizen's Charter is a document which represents a systematic effort
to focus on the commitment of the Organization towards
its Citizens in respects of Standard of Services, Information, Choice
and Consultation, Non-discrimination and Accessibility, Grievance
Redress, Courtesy and Value for Money.
Welcomed)
30

Sample of Citizen Charter
Welcomed)
31

Importance and Implication of Citizen Charter
• Makes the administration accountable and citizen friendly thus facilitating good
governance.
• Ensuring transparency and the right to information/empowers citizen.
• Taking measures to cleanse and motivate civil service.
• Adopting a stakeholder approach for the easiness of citizen approach..
• Saving time of both service provider and service taker.
• It is citizen-centric in nature, keeping in mind the needs of citizens.
• It ensures better service quality, and grievance redressal.
• Adds to the commitment and performance levels of the organization.
• ……………………
Welcomed)
32

Actors and Factors in Community Health Care System
Actors:
1. Government: ………..
2. Civil Society: …………
3. Researchers: …………
(Policy Makers, Academics, religious organizations, Profit and Non
profit organizations, Corporations, civil society, researchers, …………)
Welcomed)
33

Actors can also be written as:
Individuals
(Individuals, Family, Communities: Motivated to maintain
health and control cost
Government
Provides regulations and oversight, sets boundaries.
Offers fiduciary protection of individuals, in balance with fairness
and enterprise
Function as provider and reimbursher - as health care services,
thus acting like enterprise
Often motivated by desire to maintain political constituency
Enterprise
Supplier of services including healthcare providers, hospitals,
laboratories and pharmaceutical companies: Often motivated by
profit
Welcomed)
34

Factors in CH Care System
Physical Factors
- Industrial development(toxins and disease)
- Community size (dense community = high risk of Com. Ds)
- Environment (Dirty environment leads outbreaks, …)
- Geography (Malaria and DDs)
- Infrastructure, service delivery system
Social/Cultural Factors
Beliefs, Traditions: Circumcise in Male and FGM in Female
Prejudices: ………………..
Economy: Low economy means high prone towards disease outbreak
Politics,
Religion,
Socioeconomic Status,
Social norms
Community Organization
Ways in which communities organize their resources
Tax and non tax supported services (tax allocation and
utilization)
Eg. Usage of long lasting insecticidal treated nets, WASH,
etc.
Individual Behaviors
Takes the concerted effort of many – if not most – to make a
community voluntary program work
Proper disposal of waste products
Smoking
Sexual Activities
Factors in CHCS
Welcomed)
35

Difference between CH and PH
• Community Health is a part of Public Health
• Like community health, Public health incorporates epidemiology,
biostatistics and health services, environmental health, behavioral health,
health economics, Public policy, insurance and occupational health, ….
• Community Health is a discipline concerned with the study and
improvement of the health characteristics of different communities.
• Community health tends to focus on geographical areas, and includes
primary, secondary and tertiary healthcare.
• Community health is more action oriented with small interventions. Eg.
Estimating the environmental health risk is public health whereas
measuring the incidence of bronchial asthma cases among a group of
families at one district is community health.
Welcomed)
36

PH Development and PHC
The science and art of preventing disease, prolonging life and
promoting health through the organized efforts and informed choices
of society, organizations, public and private, communities and
individuals.
Read in Primary Health Care and International Health (PHCIH)
(203.5-PHCIH)
Welcomed)
37

CB PHC - challenges and Health Care Reform
• Primary Health Care (PHC) is always (but not only) a community based
program, with availability of many clinical services.
• Definition: PHC is essential health care made universally accessible to
individual and family in the community by means of acceptable to them,
through their full participation and at a cost that a country and community
can afford.
• 8 ELEMENTS: Education: ……. Prevention of Endemic Disease: …….
Immunization: ……… Maternal and Child Health: …….. Drug Availability:
………. Nutrition: ……. Treatment of communicable disease……., Safe Water
and Sanitation………..
• 5 principles: Equitable distribution …… community involvement ……… focus
on prevention………………, appropriate technology ………….,, multi – sectorial
approach……………
Welcomed)
38

CB PHC - Challenges and health care reform
• Unequal growth, unequal outcomes: Longer lives and better health, but not
everywhere, growth and stagnation (inactive).
• Adopting to new health challenges: A globalized, urbanized and ageing world, little
anticipation and slow reactions.
• Trends that undermine the health systems response: Hospital centrism
(selectiveness), fragmentation (health system influenced by priority programs),
health system left to drift towards unregulated commercialization.
• Changing values and rising expectations: Health equity, care that puts people first,
securing the health of communities, reliable and responsible health authorities,
participation.
• PHC reforms: driven by demands: Universal Coverage Reforms - Health equity,
solidarity, social inclusion, Service delivery reforms - people centered care,
leadership reforms - Health authorities that can be relied on: Public policy reforms
– Communities where health is promoted and protected.
Welcomed)
39

Features of Community Development/Application
• Ecological Protection: Increasing greenery, …..
• Density and Urban Design: dense building to protect agricultural lands
• Urban Infill: use abandoned infrastructure to reduce the load of demand
• Village centers: centers develop within a village for gathering and building community identity
• Local Economy: promotion of local business, inclusiveness to meet all needs of community
• Sustainable transport: free Road system for walking and driving.
• Affordable housing: Mixture of housing options, not being an exclusive housings
• Livable community: social personal development and participation of individuals in community activities
• Sewage and storm water: run off – agriculture and business water using nitrogen and phosphorus naturally, and
decrease impact of the community upon the surrounding environment
• Water: Increased need of irrigation …………..
• Energy: CO2 production increasing, increase demand of energy, ….
• The 3’R’s: Reduce, Reuse and Recycle ……
(Also Refer H/O of PH in Nepal – Last Slides)
Welcomed)
40

Functions of PH Professional
- Assessment : Assess the health need of the community, Investigate
the occurrence of health effects and health hazards in the
community, Analyze the determinants of identified health needs
- Policy Development: Advocate for pubic health, build construction,
and identity resources in the community, Prioritize among health
needs, Plan and develop policies to address priority health needs.
- Assurance: Manage resources and develop organizational structure,
Implement programs, Evaluate programs and provide quality
assurance, Inform and educate the public.
Welcomed)
41

Role of PH Professional
• Planner: ………..
• Community organizer: ……
• Coordinator: ………
• Trainer/Health Educator: ……………
• Health monitor: ………..
• Change agent: ………….
• Researcher: …………….
Welcomed)
42

Areas of PH Professional
• Assure an adequate local public health infrastructure.
• Promote healthy communities and healthy behaviors.
• Prevent the spread of infectious disease.
• Protect against environmental health hazards.
• Prepare for and respond to disasters, and assist communities in
recovery.
• Assure the quality and accessibility of health services.
Welcomed)
43

Functions of Community Health Development Staff
• Identify the health need or problems of the community by using the
various methods of community health diagnosis
• Identify the available resources and use them according to the need
of the community
• Planning of the effective programme to solve the health problem of
the community
• Formation and mobilization of the local health development
committee to implement the program and seeking the participation
of the community.
Welcomed)
44

Role of Community Health Development Staff
• As a gate keeper: …………
• As a decision maker: ………..
• As a communicator: ……….
• As a informer: ………
• As a motivator: …….
• As a teacher: …….
• As a planner: ……..
• As a facilitator: ……..
• As an advisor: ………..
• As a consultant: ………..
• As a counselor: ………..
• As a link between the health
worker and the community: ….
• As a change agent: …….
• …………….
Welcomed)
45

Essential 10 Skills necessary for CHD Staff
• Communication: ………..
• Computer : …………….
• Customer Service: …………..
• Empathy: ……………….
• Learning: ……………….
• Mathematics basic: ………………..
• POSDCORB: ………………..
• Problem Solving: ……………….
• Research and Information Gathering: ……………
• Teamwork: ……………
Welcomed)
46

Donors (Multilateral, Bilateral Organizations)
• Multilateral: Fund collected from different governments and invested
to one government. Eg. WHO, WB, UN Organizations, ADB, European
Commission, EU, ………
• Bi – lateral: Fund collected from one government and invested to
another government. Eg. USAID, USPHS, CDC (US), GIZ, SNV, AUS Aid,
JICA, DANIDA, KFW, ….
Welcomed)
47

NGOs
• A non-governmental organization (NGO) is any non-profit, voluntary
citizens' group which is organized on a local, national level.
• Task-oriented and driven by people with a common interest, NGOs perform
a variety of service and humanitarian functions, bring citizen concerns to
Governments, advocate and monitor policies and encourage political
participation through provision of information.
• Some are organized around specific issues, such as human rights,
environment or health.
• They provide analysis and expertise, serve as early warning mechanisms
and help monitor and implement international agreements.
• Their relationship with offices and agencies of the United Nations system
differs depending on their goals, their venue and the mandate of a
particular institution.
Welcomed)
48

INGOs
• NGOs crossing the country border are INGOs
• International in scope.
• Can deal with specific issues at once in many countries
• Inter governmental organizations (IGOs) are not INGOs. Eg. UN, ILO,
• Eg. Carnegie, Rockefeller, Gates, SOS Children’s villages, Oxfam, Care
International, etc.
Apart from "NGO", there are alternative or overlapping terms in use, including: third-sector
organization (TSO), non-profit organization (NPO), voluntary organization (VO), civil society
organization (CSO), grassroots organization (GO), social movement organization (SMO), private
voluntary organization (PVO), self-help organization (SHO) and non-state actors (NSs).
Welcomed)
49

CBOs and Local Group
• CBOs are nonprofit groups that work at a local level to improve life for
residents.
• CBOs focus building equality across society in all streams – health
care, environment, quality of education, access to technology, …
• CBOs are staffed by local members – who experience first hand need
of their community.
• Works conducted by CBOs generally falls into the theme of human
services, natural environment conservation or restoration, and urban
environment safety and revitalization
Welcomed)
50

Contd ….
• Local group are loose network of people having common objectives or
sharing.
• Local groups when are organized, it becomes CBOs.
• Local groups are first level of people who seek change
• Multiple local groups can form CBOs.
• Local groups are necessary to preserve the local identity of the community.
• variety of people with different skills, ideas and resources form different
local groups to address particular issues, which if organized becomes CBOs.
• Eg. FCHV, MG, Utilizers group, HFOMC/HDC, etc. …….
Welcomed)
51

Emerging concept of CD
• Decentralization
• Cooperative
• Livelihood
• Sustainable Development
Welcomed)
52

Decentralization
• Decentralization is a systematic delegation of authority at all levels of
management and in all of the organization.
• Everything that increases the role of subordinates is decentralization and
that decreases the role is centralization
• Other than critical decisions can be done by managers of subordinates.
• Decentralization pattern is wider in scope
• Decentralization of authority means dispersal of decision making power to
the lower level organization.
• Decentralization refers to the systematic effort to delegate to lowest level
of authority except that which can only be exercised at central points.
• Decentralization differs from delegation
Welcomed)
53

Definition
The transfer of responsibility for planning, management, and resource
raising and allocation from the central government to:
• Field units of central government ministries or agencies,
• Subordinate units or levels of government,
• Semi-autonomous public authorities or corporations,
• Area-wide regional or functional authorities, or
• Organizations of the private and voluntary sector.
Source: Rondinelli, D. (1981).
Last bullet has been modified from the original statement to include private
enterprise and the entire voluntary sector.
Decentralization reforms focus on:
• The relationships between three major sectors of governance, namely, the public sector, the private sector,
and the voluntary sector; and
• Within the public sector, decentralization focuses on the structure and processes of decision making and on
resource and responsibility allocation among different levels of government.Community Health Development: Draft Version 5 (Feedback
Welcomed)
54

Determinants of decentralization
• "The number of major ethnic groups"
• "The degree of territorial concentration of those groups"
• "The existence of ethnic networks and communities across the border
of the state"
• "The country’s dependence on natural resources and the degree to
which those resources are concentrated in the region’s territory"
• "The country’s per capita income relative to that in other regions"
• The presence of self-determination movements
Welcomed)
55

Averting the dangers of decentralization: Eight
Classic Conditions
• Social Preparedness and Mechanisms to Prevent Elite Capture.
• Strong Administrative and Technical Capacity at the Higher Levels.
• Strong Political Commitment at the Higher Levels.
• Sustained Initiatives for Capacity-Building at the Local Level.
• Strong Legal Framework for Impartiality, Transparency and Accountability (TIA)
• Transformation of Local Government Organizations into High Performing
Organizations.
• Appropriate Reasons to Decentralize: Intentions Matter.
• Effective Judicial System, Citizens’ Oversight and Anticorruption Bodies to
prevent Decentralization of Corruption.
Welcomed)
56

Implication of decentralization
• Less burden on the Chief Executive as in the case of centralization.
• Subordinates get a chance to decide and act independently.
• Operations can be coordinated at divisional level.
• Co-ordination to some extent is difficult to maintain.
Welcomed)
57

Challenges of decentralization in community participation
• The quality of game cant be improved by only changing the name of team rather
than changing the players.
• Increased Cost
• Complexity in coordination
It can also be understood as:
• Political Challenge: Democratization, Citizen Participation, Legitimate Government
(s), e.g.. Structure for decentralization, lack of political will
• Administrative Challenge: Transfer of function with regards to planning,
management, allocation of resources, e.g.. Planning, financing and monitoring,
• Fiscal Challenge: Assignment of revenues to local governments so that they can
discharge their responsibilities. Sometimes related to local revenue generating
capacities. Finance and cost related
• Market Challenge: Transfer of some responsibilities from states domain to market.
Resources.
Welcomed)
58

Concept of cooperative
• The first cooperative was organized in US in 1752.
• It follows user centered principles (user owned, user controlled and
user beneficiary)
• Cooperative can be developed in any field: Agriculture, Arts and
Crafts, Business, Child and Preschool, credit unions, custodial and
cleaning services, food cooperatives and buying clubs, hardware
wholesale, housing, insurance, student, Utility, workers, etc. ….
• New generation cooperative: (6 characteristic) Defined membership,
Delivery rights, Up fronting equity, delivering rights and fluctuation of
values, marketing agreement, Membership and legal relation.
Welcomed)
59

Cooperative Definition.
• “An autonomous association of persons united voluntarily to meet
their common economic, social, and cultural needs and aspirations
through a jointly-owned and democratically-controlled enterprise“
• Shared Principle of Cooperatives: Voluntary and open membership,
Democratic Member Control, Member Economic Participation,
Autonomy and independence, Education – training and Information,
Cooperation among cooperatives, Concern of community.
• There are various health care cooperatives providing different
functions. (Insurance, Central database)
Welcomed)
60

Cooperative Strategies
• It is a planning strategy where two or more firms work together to
achieve a common objective.
• It helps increasing profit for the organization.
• It gives advantage to the company: strengthening that lack
competitiveness, resource utilization
• Form strategic alliance: Joint Venture, Equity Strategic Alliance,
Nonequity Strategic Alliance. (Wiki)
• According to Market, 3 types of Cooperative alliance: Slow Cycle
Market, Fast cycle Market, and Standard cycle market
Welcomed)
61

Cooperative approach of community development
• It’s a spiral cycle of policy formation (update) and cooperative
formation: ……………
• Development in community interest: …………….
• Flexibility in profit making: ……………
• Financial Advantages: …………….
• Development of Human, Social and financial Resources: ……….
Welcomed)
62

Types of Health Cooperatives
• Consumer cooperatives:
• Purchasing/Shared service Cooperatives
• Worker Cooperatives: (eg. Lam Unique Special Care and Case
Management. Inc., Cooperative care, ……)
(Health Security, Community Support, Participation)
Welcomed)
63

Consumer Cooperative
Consumer cooperatives are enterprises owned by consumers and
managed democratically which aim at fulfilling the needs and
aspirations of their members.
They operate within the market system, independently of the state, as
a form of mutual aid, oriented toward service rather than pecuniary
profit.
eg. Group Health Cooperative, Health Partners, ……
Welcomed)
64

Purchasing/Shared service Cooperatives:
A shared-services cooperative is a business organization owned and
controlled by private businesses or public entities that become
members of the cooperative to more economically purchase
services and/or products.
Members of shared-services cooperatives respond jointly to common
problems.
eg. council or smaller enterprises, Pac Advantage, ……….)
Welcomed)
65

Worker Cooperatives
A worker cooperative is a cooperative that is owned and self-managed
by its workers.
A cooperative enterprise may mean a firm where every worker-owner
participates in decision-making in a democratic fashion, or it may refer
to one in which management is elected by every worker-owner, and it
can refer to a situation in which managers are considered, and treated
as, workers of the firm.
Eg. Lam Unique Special Care and Case Management. Inc., Cooperative
care, ……
Welcomed)
66

Livelihood - Concept
• Making a living
• It includes social and cultural means.
• Encompasses peoples capabilities, assets, income and activities.
• It becomes sustainable when it enables people to cope with and
recover from shocks and stresses (natural disaster, economic or social
upheavals) and enhance their well being and that of future
generations
Welcomed)
67

Livelihood - definition
A set of activities, involving securing water, food, fodder, medicine,
shelter, clothing and the capacity to acquire above necessities working
either individually or as a group by using endowments (both human
and material) for meeting the requirements of the self and his/her
household on a sustainable basis with dignity.
Welcomed)
68

Sustainable Livelihood Framework (Process)
Welcomed)
69

Sustainable Livelihood Development - Framework
• Factors that make a livelihood more or less vulnerable to shocks,
trends and seasonality.
• Relationship of Livelihood Assets (Human Capital, Social Capital,
Natural Capital, Physical Capital, Financial Capital)
• Structure and Process development for livelihood
• The strategies they develop to make a living
• The context within which a livelihood is developed
• Measured in terms of outcomes achieved
Welcomed)
70

Complex Process of livelihood
Welcomed)
71

Effect of livelihood on health and maintenance
• Effect on Water and Sanitation Hygiene (WASH): ….
• Effect on agriculture, food and livestock: ……..
• Changing pattern of disease and drug resistance: …….
• Urbanization and population growth/decline trend: ……….
• Dynamics in scientific findings. Eg. Usage of CFL bulb: ……..
• Update in technologies (farming, IT, nanotechnology and genetic
engineering, …..): ……..
• Development of System – D and its impact on health: …………..
Welcomed)
72

Three Pillars for Sustainability
Welcomed)
73

Approaches for sustainability
• Integrated Management
• Inter Generational Equity
• Precaution
• Proportionality
• Life cycle approach
• Prevention
• Substitution
• Internalization of cost
(destroyer pays)
• Public Participation
• Right to Know
• Confidential Information
• Good governance
• Cooperation among states,
including common but
differentiated responsibilities
• Partnerships
• Liability
Welcomed)
74

Rio+ 20 and SDG
• AKA United Nations Conference on Sustainable Development
(UNCSD) hosted by Brazil in Rio de Janerio (13 – 22 June 2012).
• It was 3rd international conference on Sustainable Development.
• It had 3 objectives:
➢Securing renewed political committeement for sustainable development.
➢Assessing the progress and implementation gaps in meeting previous
committeements
➢Addressing new and emerging challenges.
• It had 2 themes:
➢Building Green Economy
➢International coordination (Institutional Framework)
Welcomed)
75

Major Outcomes of UNCSD
• It supported the development of SDGs.
• UN Environment Program (UNEP) was incorporated for “leading global
environmental authority” (including government strengthening and universal
membership, increasing financial resources and strengthening its engagement in
key UN coordination bodies.
• Nations agreed to explore alternative to Gross Domestic Product (GDP) as a
measure of wealth and pay “environmental services” like carbon tax.
• Recognition that "fundamental changes in the way societies consume and
produce are indispensable for achieving global sustainable development." i.e.
Workers pay less and polluters and landfill operators pay more.
• Returning of Ocean Stocks as urgent.
• Phase out of fossil fuel.
• Other 400 voluntary commitments were made.
Welcomed)
76

Green Economy
• It aims reducing environmental risks and ecological scarcities, and
also aims to sustainable development without degrading the
environment.
• It is defined under 6 main sectors: Renewable Energy, Green
Buildings, Sustainable Transport, Water Management, Waste
Management, Land Management.
• It was criticized for being based on price mechanism to protect
nature. Eg. Carbon tax.
• Was also criticized as real drivers to create environmental crisis
(economic growth addressing environmental loss)
Welcomed)
77

Factors of Sustainability (17 Goals of SDG) 169 targets
Welcomed)
78

Challenge and critiques
• Competing Goals: Contradictory e.g.. Increase in GDP growth might
undermine ecological objectives, increasing empowerment and wages
can work against reducing the cost of living.
• Too many Goals: 169 targets might be “sprawling, misconceived” and
a “mess”.
• High Cost of achieving SDG: Estimate of $2 - $3 trillion USD per year
for next 1 years which is called as ‘pure fantasy”
• Responses to criticism: As an feedback to MDG, SDG has not only
addressed problems, but also causes of problems.
(Wiki)
Welcomed)
79

Global PH Development and PHC.
Read in Primary Health Care and International Health (PHCIH)
(203.5-PHCIH)
Welcomed)
80

History of PH in Nepal
• 1st century – 879 AD: Ancient
• 879 – 1768 AD: Medieval
• 1769 onwards: Modern
Welcomed)
81

Ancient Era
• Before Ancient Era (Pre historic time), we find the history of Hanuman going to
Dhaulagiri hill in search of medicines, Jesus giving life to Lazarus, and healing sick,
Sri krishna giving life to Parikshit (son of Uttara/Grandson of Arjun). Srustha
Samhita (Part of Ayurveda) was originated in 6th Century BC and was updated by
Buddhist Monk – Nagarjuna in 2nd Century BC. Head transplantation of Dadichi with
horse by asvins – first physician to perform organ transplant surgery, Ganesh by
Elephant, Dakshyaprajapati by goat (plastic surgery), Jarashand was born by joining
two halves delivered from different mothers.
• Lichhavi Kings - Amshu Barma (605 – 620): Aarogyashala (Hospital), cutting
umbilical cord immediately after the baby is born and not to wait till the placenta is
expelled.
• Narendradev (643 – 679) and Mandev ( 464 – 505) give directions to be followed
by general population on the safe motherhood practice. (CS in case mother dies to
save child), caring of pregnant and newly delivered mother by husband.
• ………………..
Welcomed)
82

Medieval Era
• Pratap Malla ( 1641 – 1678) established a traditional medicine
(Ayurveda Dispensary) in Hanumandhoka which were encouraged by
the kings of Bhaktapur and Lalitpur. Singhadurbar Baidyakhana is the
continuation from Pratap Mallas time.
• Christian missionaries working in Pecking, China and Lasha introduced
1st allopathic medicine in Nepal.
• In 1661 Jesuit Father Grueber and Dorville and associates entered
Nepal (Kings were: Pratap Malla – Kathmandu, Siddinarsingh Malla –
Patan and Jagajyoti Malla – Bhaktapur) and were allowed to stay in
valley to support for the epidemics control of plague and cholera, but
later were expelled from valley for their missionary activities.
Welcomed)
83

Contd …
• Capuchin monks established a small mission office in Kathmandu in 1715 AD.
• Father De Recanti continued to work in Bhaktapur and it is widely believed that he
also established a missionary office in Bettiah too, a small state in Indo-Nepal
border.
• in 1763 AD, during war of Kantipur and Gorkha at Kirtipur - Prince Soor Pratap
Shah of Gorkha got injury in eye. The capuchin monk Michael Angelo was
called and he treated the wounded prince.
• Though, Capuchin Monks were expelled by Mallas, they were again brought to
Kathmandu to treat King Singa Pratap Shah to treat small pox, though he died in
1777.
Welcomed)
84

Modern Era
• It is divided into three phases:
• First Phase: Medical Service from British Resident Doctors
• Second Phase: Rana Period, and
• Third Phase: Post Democracy Period
Welcomed)
85

British Residency and the Medical Services
• Captain Knox as the resident and Dr FB Hamilton as the resident
surgeon appointed for residency office in Nepal in 1802 AD.
• Dr. H.A. Oldfield was appointed as the resident
doctor in 1850 to 1863 AD who had also introduced vaccination in
1850 AD, which was given to the children and family of Jung Bahadur
Rana.
• Dr Wright replaced Dr Oldfield in the British residency. In
1883 AD, Dr. Adar Nath treated Commander-in-Chief General Dhir
Shamsher, General Bhim Shamsher for abdominal colic in 1884 AD
Welcomed)
86

Rana Period: State initiative to establish medical services
• Many modern and traditional hospitals were established as a state
initiative, and as human resources were not available in Nepal, were
brought from India.
• Khokana Leprosy Asylum was established by the state in 1857 AD to
isolate the leprosy patients.
Welcomed)
87

During Bir Shamsher ( 1885 – 1901)
• The hospital named collectively after
the then King Prithvi Bir Bikram Shah (1880-1913 AD) and
Prime Minister Rana Bir Shamsher as Prithvi- Bir Hospital.
• Cholera Hospital was established in Teku,
Kathmandu near rope way station.
• Additional Prithvi-Bir group of hospitals were established in the same
year in Birgunj, Jaleshwar, Hanuman Nagar, Taulihawa and Nepalganj.
Leprosy Hospital was also established in Tripureshwar.
Welcomed)
88

Chandra Shamsher (1902 – 1929)
• 1903 - Chandra Lok Hospital established in Bhaktapur
• The second-generation hospitals were established in the name of the then
King Prithvi Bir Bikram and Prime Minister Chandra Shamsher as Prithvi-
Chandra group of hospitals.
• Prithvi-Chandra Hospitals were established in Palpa, Palhi, Doti, and Ilam.
• New group of hospitals as Tribhuvan-Chandra Hospitals established in
Dhankuta, Bhadrapur, Sarlahi, and Rangeli.
• In 1925 AD 64-bedded Tri-Chandra Military Hospital was established in
Kathmandu in the commemoration of the war heroes of the First World
War.
• Prithvi-Bir Hospital in Kathmandu was further strengthened with
establishment of the separate Women’s Hospital, radiology and laboratory
units and Chandra Sales Dispensary.Community Health Development: Draft Version 5 (Feedback
Welcomed)
89

Contd ….
• Nardevi Ayurvedic Hospital was established in 1918 and parallel Ayurvedic
dispensaries were established in districts along with the modern medicine
hospitals.
• He also established Lalitpur Hospital in Patan in 1924 AD.
• The expansion work of Khokna Leprosy Asylum to sanatorium and
construction of Tokha Tuberculosis Sanatorium were also started during the
premiership of the Rana Chandra Shamsher.
• Eighteen hospitals and 14 dispensaries got established during his
premiership.
• Kharga Hospital was established in Bajhang by Jaya Prithvi Bahadur Singh
from non-governmental sector during the tenure of the Chandra Shamsher
Welcomed)
90

PRIME MINISTER BHIM SHAMSHER 1929-1932 AD
• He established Tri-Bhim Hospitals in Bhairahawa, Butwal and
Bahadurganj.
• Ramghat dispensary at Pashupati was inaugurated in 1929 AD and
further dispensaries were established in Sindhulimadi,
Ramechhap, Okhaldhunga, and Pashupatinagar.
Welcomed)
91

PRIME MINISTER JUDDHA SHAMSHER 1932-1945 AD
• He established Tri-Juddha group of hospitals in 1931 AD in Dharan and
in 1940 in Bhimphedi, Bardiya, and Kailali.
• Tokha Tuberculosis Sanatorium (40 bed) came in operation in 1935 AD
• Leprosy Asylum in Khokana, Kathmandu was upgraded to sanatorium
and new leprosy sanatorium constructed in Malunga, Syangja also came
in operation in the same year.
• Leprosy department and treatment center was established at Pachali
(shifted from Tripureshwar) in 1937 AD.
Welcomed)
92

PRIME MINISTER - PADAM SHAMSHER (1945-1948
AD) AND MOHAN SHAMSHER (1948 –1951 AD)
• Health services established by their predecessors were strengthened
during their tenure.
• One health center was established in Sankhu in 1949.
• Homeopathic dispensary was opened and a chest clinic (1951) was
started in Bir Hospital.
• School health program initiated during this period.
Welcomed)
93

Post – Democracy Period
New health policies and programs and involvement of non governmental
organizations health care (NGOs) - 1951-1963 AD
• Planned development process started.
• Health Centers were established in Banepa (1954), Dailekh (1955),
Ramnagar Bhutaha (1956), Chainpur , Sankhuwasabha (1957), Hospitals at
Biratnagar, Dang and Baglung at 1656, 1957 and 1958 respectively, Kanti
Hospital, 1962, etc. …..
• Missions funded NGOs (Shanta Bhawan Hospital – 1954), Suryabinayak
Hospital 1954, Sheer Memorial Hospital 1957, Pokhara Shinning Hospital
1957, Amp Pipal Hospital – 1957, Okhaldhunga Hospital – 1963, Bulingtar
Hospital – 1962, Palpa – 1954, Maternity Hospital – 1958, etc.
Welcomed)
94

Contd …
Regionalization of health services - 1964 - 1974 AD
• Zonal Hospitals were established.
• Kanti Hospital was converted into Children's Hospital by merging with
pediatric department of Bir Hospital.
• ICU/CCU were opened in Bir Hospital.
• Nepal Tuberculosis Association opened Tuberculosis Hospital in
Kalimati – 1970
• Many health centers were upgraded to health post and district
hospital
Welcomed)
95

Contd …
Emergence of single specialty hospitals and implementation of primary
health care system (1975-1992) AD
• Special hospital in psychiatric and eye were opened
• SLTHP was prepared and PHC system was implemented
• Community level Health Posts, district hospitals were established.
• Gandagi Zonal Hospital was upgraded to Western Regional Hospital.
• National TB Centre was established in Bhaktapur
• Psychiatric department was merged with new Mental Hospital in Lagankhel
• Teku Hospital was separated from Bir Hospital and received independent
infectious disease hiospital status and was upgraded to national level
hospital.
Welcomed)
96

Contd…
• Homeopathic hospital was upgraded
• Traditional medicine dispensaries were established in community level
• High Level manpower production started with intensified low level
manpower.
• Small Pox eradication goal was achieved and Expanded Immunization
Program started.
• TUTH in 1986 and Birendra Police Hospital in 1984 were established
• NGO sector established Nepal Eye Hospital in 1980 in Kathmandu/.
• Orthopedic hospital was established in Jorpati
• Additional Eye Hospital were established (Tilganga and Lions eye care
center) by NGO.
Welcomed)
97

Contd…
Emergence of tertiary care centers and expansion of primary health care
and growth of private health institutions 1993- 2002 AD
• Tertiary services started in Neurosurgery, Cardiac Surgery and Cancer from
Public Sector.
• Many traditional medicine treatment centers were established.
• Polio Eradication Program started.
• DOTS strategy was started.
• BP Koirila Cancer Hospital (1995) – Chitwan, Sahid Gangalal National Heart
Centre (1997) – Kathmandu, Manipal College (1997), Kathmandu Medical
College and Teaching Hospital (2000), Nepalgunj Medical College and
Teaching Hospital ( 2002), Sushma Koirila memorial Plastic and
Reconstructive Surgery Hospital (1999) in Sankhu, …….
Welcomed)
98

Contd ….
Closure of the hospitals
• Due to reconstruction of Health Services, many hospitals were closed.
• Tokha TB Sanatorium and Malunga leprosy Sanatorium were closed.
• Sovereign Remote Health Centre for those hospitals after Mission
Left.
• Dharan Hospital and British Gorkha Army Hospital merged and than
transferred to BP Koirila Institute of Health Sciences.
• Lalitpur Hospital and Santabhawan Hospital Merged to form Patan
Hospital.
• There is a big health transformation after being a federal state.
Welcomed)
99

End
Welcomed)
100

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