|
The Selection Process:
One of the key issues in
Community Health Worker programmes has been the selection of the health
worker. One general principle emerges that since the purpose of such a
programme is to reach the unreached as effectively as possible, persons
who are selected as community health workers must be sensitive and have
empathy with the poorest and the most marginalized, if not be someone
drawn from their own ranks. Another equally important principle is that if
it is indeed community action then such a person must be owned by the
community as acting on its behalf- not at the behest of the government ,
much less a philanthrophic institution or funding agency. Of course both
these principles flow from a perception of health worker as part of a
social process for empowerment- for social and economic justice. There are
philanthrophic initiatives which see health care as charity or benovelence
for whom such criteria would not be necessary. But as the ActionAid motto
goes: what is needed in the world is not charity it is justice. If we
accept this premise then the best way of attaining these values is when
the facilitating organisation has a close tradition in working with the
community for securing the rights of the poor. And the longer their
presence and the deeper their work the more likely they are to make the
right choice. Indeed Organisations like CEHAT would call for a prolonged
contact on rights based work over one to two years before the process of
health worker selection is initiated. There is really no other certain way
of knowing that a selection is correct.
The limitation of this
understanding would be that the programmes can be expanded only to such
areas where there is we have a rights based organisation deeply involved
with the community and having the surplus energy, time and resources to
allot to taking on health care – which would be a very small area indeed.
To be precise in the state of Chattisgarh it would have been limited to
about 13 blocks and within that about 40 villages to a 100 villages in
each.- just about the area where the pilot programmes were launched.
Expansion beyond it is not possible if such close community contact
becomes a precondition.
When one addresses the larger
question of the state taking responsibility and even a state run community
health worker programme – the selection process becomes a choice between
letting the peripheral health worker choose her assistants in the form of
community health workers or leaving it to panchayat sarpanch. Even where a
sarpanch is motivated and represents weaker section given the lack of any
tradition of consultation and given the precedence of treating such
appointments as patronage the sarpanch is likely to choose a family member
or some one who he is obliged to. And this problem is much worse if there
is any honararium or even a training stipend attached – however small the
amount. Since in most villages the sarpanch is often part of a local
privileged section, sometimes even hostile to weaker sections, these
choice is even less likely to serve weaker sections.
When it is a multipurpose
worker ( MPW) making the choice she usually settles for whosoever she can
persuade to take up the task, and the village may never really accept or
cooperate with this. Often she herself belongs to the better off sections
by caste and economic background and her ability to recruit is confined to
these sections.The motivation and effectiveness of such a choice remains
low. This in turn would only reiterate her poor opinion of community
participation itself -which is the dominant view within the public heath
sector.
The Mitanin programme tries to
contend with this problem by three major innovations:
·
The trained facilitator:
The village must make the choice. This is critical.
And this must be made in a general body of the village or at least a
meeting with good attendance. But for the village to make a correct choice
it must be well informed about the programme and be able to clarify what
is expected of the village and of the Mitanin. A trained facilitator
undertakes this task. An even more important task of the facilitator is to
ensure that all the sections( stakeholders in current parlance)in the
village are informed and discussed with separately and that the views and
needs of the weaker sections and the women are articulated and find place
in the final decision. This requires that the facilitator can identify
different points of view and negotiate between them with a partisanship
for the poorer amongst them. A five or six day training programme has been
devised specifically to impart the necessary understanding and skills.
Further the choice of the facilitator itself becomes a one or two month
process with a small process for constitution of the district group who
would choose the facilitators. A guidebook for this training and detailed
guidelines on the selection process and evolution of careful indices for
monitoring these processes form part of the strategy.
·
Hamlet as unit of programme:
Another specific innovation of the programme is the
choice of the hamlet as the unit of the programme-in contrast to earlier
programmes, which used the village as a unit. Different groups occupying
different positions in the power relationships, especially those based on
caste- tend to inhabit different hamlets and by providing for a Mitanin
per hamlet we ensure that all these sections participate: Choosing a
Mitanin per hamlet means also a lesser number of families for each Mitanin
to cover – usually 30 to 50 families which makes the work feasible on a
voluntary basis. Moreover since in this state most villages are made up of
highly dispersed hamlets sometime over a few kilometres, it is not even
possible for one Mitanin to cover the whole village. Finally the intensity
of coverage is so high that the diffusion of health education messages and
its penetration to the furthest habitations is almost guaranteed if over
54,000 Mitanins go through this intensive 50 day process. On the flip side
the change from village to hamlet means that numbers multiply from under
20,000 to over 54,000 with the attendant increase in costs and problems of
programme management involved in providing support and training to so many
more.
·
Social Mobilisation:
The process of selection is not going to be
effective unless there are many women who volunteer to take up this task
and from whom based on criteria the most suited is selected. Even those
women not selected as Mitanins would be involved in the women’s
committees. The process of selection is also not going to be effective if
the village does not enthusiastically take part in the selection process
thereby owning the programme as its own. But for this to happen one needs
not only knowledge and motivation but also a certain additional factor –
the collective will to action. The process of generating this is what has
been termed social mobilisation. A charismatic leader or very respected
proactive individual may elicit this but such a person is not available in
most villages. Often a successful local developmental initiative or
peoples movement has created the enthusiasm and the readiness to embrace
such initiatives. In many villages in Chhattisgarh, women’s credit
cooperatives have played this role. But even these are too few to cover
even a significant number of hamlets. Therefore in addition to other
dimensions a social mobilisation campaign centred on the kalajatha is
built into the selection phase. This role of the kalajatha is a lesson
learned from the mass literacy campaigns of the nineties, which was
spearheaded by kalajathas largely initiated and organised by the Bharat
Gyan Vigyan Samiti. The kalajatha, a travelling troupe of artistes uses a
carefully constructed set of plays and songs prepared by the best of
playwrights and musicians of this genre and it uses the local cultural
idiom and art forms to convey the spirit of the programme and its
objectives. In the rural context this is very effective – a way in which
the message is easily internalised by its audience. Along with the
meetings, the conventional forms of publicity and the group discussions
before and after the kalajatha establish social mobilisation for this
programme. |
