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IGNOU R.D.D.-006 Rural Health Care Free Solved Assignment

ASSIGNMENT REFERENCE MATERIAL (2017-18) FREE

Long Answer  Questions

Attempt any One of the following:

Q1. Describe the factors influencing health and nutrition status in rural India.

Ans.   The broad factors considered to be influencing health and nutrition status are:

(1) Nature of Social and economic development: Socio-economic development is the process of social and economic development in a society. It is measured with indicators, such as gross domestic product (GDP), life expectancy, literacy and levels of employment. For better understanding of socio-economic development, we may understand the meaning of social and economic development separately.

Among many factors influencing health, access to public health and modern medicine, socio-economic development and the natural biological changes are considered crucial. If we analyse the changes in mortality rates that have occurred over the last eight decades, we find that increasing access to public health and modern medicine is the primary reason for such changes. But it is easily seen that this can, at best, only be a very minor factor because in the pre-Independence period, access to public health and modern medical care was limited to a very small fraction of the population.

The role of natural biological changes has also been to explain the increase and decline of disease in the natural cycle of any epidemic and the cyclical nature of occurrence of epidemics in any population as evidence of natural change processes. Both the disease organism and the human host adapt to each other over time by changes in virulence of the organism and immunity of the host.

While foodgrain availability increased from 424 gm per capita per day in 1976 to 475 gm in 1990, calorie consumption itself has remained about the same during this period or has declined. The expectation that public distribution would ensure access to the produce in all parts of the country has not materialised, specially in rural areas. So the rural population living in less fertile and poorly irrigated regions (which was the most malnourished) did not get much benefit from extra production. Many subsistence producers were converted into buyers of food.

(2) Socio–economic status of poor households: Poverty means economic uncertainty and insecurity. It means being constantly engaged in balancing between options so as to ensure survival and make optimal use of what one has. In a situation of insecurity about obtaining basics for survival, the choice naturally tends to fall on the option, which provides support for the present struggle for survival, hence long-term considerations becoming secondary. The services are provided without concern for this dilemma of the poor. They are designed in such a way as to make the two options mutually exclusive. A system of schooling, which would allow the child to get educated even while earning, would provide some solution to both long and short-term goals. The quality of services provided and the attitude of the service providers are also important factors.

Delayed supplementary feedings (i.e. feeds in addition to breast milk) was earlier thought to be a major reason for infant malnutrition. It was advocated that it should be started at 3 months of age. But the danger of diarrhoea increases manifold with supplementary feeding when the village mothers are unable to boil the feeding bottle or cook the food fresh every time or store the cooked food hygienically for long. The diarrhoea can mean more malnutrition and even death. Now, paediatricians too have realised this and advocate supplementary feeding to poor mothers only by six to nine months. On the other hand for malnutrition among the better-off, be it obesity (over–nutrition) or deficiency of nutrients, unhealthy behaviour is probably a much more important causative factor.

(3) Socio-cultural Factors: Socio-cultural factors are the elements that are related to or pertaining to the combination or interactions of social and cultural habits. Some of these factors are: social taboos, gender roles, religious conservatism, etc. These are increasingly being applied by educationalists to enhance learning. Socio-cultural factors are the larger scale forces within societies and cultures that affect the thoughts, behaviours and feelings of individual members of those societies and cultures. Examples of socio–cultural factors include aesthetics (appearance), language, law, politics, religion, values, attitudes, social organisations, reference groups, family, a person’s role and status in their chosen society, technology and material culture. These issues can become very important for small business owners, because they need to target their promotions based on the socio-cultural factors that are at play. For example, when a society or culture has a higher percentage of individuals that have attended post–secondary institutions, it is reasonable to assume that using more details and explanations when promoting a product is acceptable.

(4) Population Growth: It is obvious that more the number of family members, more will be the requirement of food and all other needs, and therefore, greater will be their deficiency. Thus, a large number of children (i.e. more than the officially prescribed ideal) of the rural poor are a major cause of their malnutrition and ill health. However, this logic seems to apply differently in the rural situation. The land-owning families may need more hands on the land so more children are economic asset. For the labouring poor, the children are even more valuable because they supplement income since very young — a significant input into a very insecure economic situation. They, thus, add much more and take out much less from the domestic budget. More children are considered desirable by the rural people. In addition, the high child mortality means that more children must be born for achieving the desired family size. They do practise family planning according to their own logic, which is evident by the fact that the total number of children born to rural families is much below their biological capacity, thought to be more than the ‘one or two’ norm advocated officially.

Q2. Explain the major environmental sanitation problems in India.

Ans.   The major environmental sanitation problems in India are basically associated with following factors:

(1) Water: Water is essential for life. Provision of safe adequate water for human population is a pre–requisite for good health. Ancient civilisations grew up along rivers and places where water was conveniently available. Excavations of Mohanjodaro in Indus river valley and Lothal near Bavla in Ahmedabad district reveal striking achievements in water supply and drainage.

The role of the WHO Guidelines for Drinking Water Quality emphasises an integrated approach to water quality assessment and management from source to consumer. It emphasises on quality protection and prevention of contamination and advises to be proactive and participatory and address the needs of those in developing countries who have no access to piped community water supplies. The guidelines emphasise the maintenance of microbial quality to prevent waterborne infectious disease as an essential goal. In addition, they address protection from chemical toxicants and other contaminants of public health concern.

The positive impact of improved water quality is greatest for families living under good sanitary conditions, with the effect statistically significant when sanitation is measured at the community level but not significant at the household level. Improving drinking water quality would have no effect in neighbourhoods with very poor environmental sanitation; however, in areas with better community sanitation, reducing the concentration of faecal coliforms by two orders of magnitude would lead to 40 per cent reduction in diarrhoea. Providing private excreta disposal would be expected to reduce diarrhoea by 42 per cent, while eliminating excreta around the house would lead to a 30 per cent reduction in diarrhoea. The findings suggest that improvements in both water supply and sanitation are necessary if infant health in developing countries is to be improved.

(2) Air Pollution: Air pollution in India is a serious issue with the major sources being fuel wood and biomass burning, fuel adulteration, vehicle emission and traffic congestion. Air pollution is also the main cause of the Asian brown cloud, which is causing the monsoon to be delayed. India is the world’s largest consumer of fuel wood, agricultural waste and biomass for energy purposes.

Air pollution is a growing menace to health throughout the world. Air pollution sources may be classified into four broad categories:

• Industrial processes: Emission of chemicals into air from chemical and metallurgical industries, oil refineries, fertiliser factories, etc.;
• Combustion: Burning of coal, oil and other fuels in houses and in factories adds smoke, dust and sulphur dioxide to air;
• Motor Vehicles: Pollution through their exhausts, they add to air

(3) Housing: Housing is part of the total environment and to some extent is responsible for the status of man’s health and well-being. Besides ‘physical structure’, housing also includes the immediate surrounding and the related community services and facilities. The WHO prefers to use the term “residential environment” which is defined as the physical structure that man uses and the environs of that structure including all necessary services, facilities, equipment and devices needed or desired for the physical and mental health and the social well-being of the family and the individual.

Although light, air and space are available in villages and small towns, there is no organised plan for housing. People live in dark, ill ventilated, damp and overcrowded houses built back to back. Most houses are without bathroom or latrine. Wastewater, cow dung, refuse accumulate inside and outside of most houses where flies and mosquitoes breed creating lot of unhygienic surroundings. Poor housing in villages is due to ignorance, poverty, traditions, fear of theft and dacoity, apathy and indifference. Similar haphazard planning is also observed in many old towns and cities. Overcrowded, ill-ventilated and unhygienic housing are all directly related to increase in morbidity and mortality rates. They also have indirect effect on mental and social health. “Recent estimates of the premature deaths in India from indoor air pollution exposures range from 500,000 to two million per year”.

(4) Disposal of Wastes: Wastes constitute an important part of the environment of man. Standard of public health largely depends on the efficiency with which all waste products of the community are collected, removed and disposed of. The main waste products of community living are refuse or solid waste, human excreta or night soil and sullage. The term refuse is applied to all solid waste from human habitation and includes public refuse and industrial refuse. The term litter is sometimes used in place of refuse for solid waste in rural areas.

The methods for disposal of waste are different in rural and urban communities. In villages, methods followed are based on tradition, socio-cultural factors, simplicity and economy. But in urban areas, sanitary measures are enforced by municipal laws.

(i)        Refuse Disposal: Refuse is to be disposed properly to maintain environmental sanitation. Various methods used are dumping on vacant land, sanitary filling or controlled tipping (refuse covered with a layer of earth) incineration or burning, disposal into the sea or rivers, composting (combined disposal of refuse with human of animal excreta forming a good organic manure (compost) for agricultural purposes).

(ii)       Excreta Disposal: Safe disposal of excreta is of paramount importance for health and welfare and also for the social and environmental effects it may have in the communities involved. It is of primary importance in any community to make suitable arrangements for the collection, removal and disposal of excreta.

 (iii)    Sullage Disposal: Wastes water from houses, etc. unmixed with solid excreta is usually known as sullage. In towns and cities, sullage water is disposed either in the sewer system or by the surface drainage system. The problem arises in village where there is no proper arrangement for disposal of sullage water. To avoid haphazard water collections and problems of fly mosquito breeding, the sullage water can be disposed through construction of soakage pits which dispose of wastewater by absorption into porous soil on a small scale.

Q3. Describe the following innovative experiments of NGOs in health care:

(i) Comprehensive Rural Health Project, Jamkhed, and

Ans.   CRHP works by mobilising and building the capacity of communities to achieve access to comprehensive development and freedom from stigma, poverty and disease. Pioneering a comprehensive approach to primary community-based healthcare (also known as the Jamkhed Model), CRHP has been a leader in public health and development in rural communities in India and around the world. The work of CRHP has been recognised by the WHO and UNICEF and has been introduced to 178 countries across the world. Annually, CRHP provides services that directly impact half a million people in the state of Maharashtra. Since the opening of the Training Center in 1994, over 22,000 local and 2,700 international representatives from NGOs, governments and healthcare professionals have been trained in the CRHP approach. At the core of this comprehensive community-based approach is its embrace of equity for all, utilising healthcare as a means to break the cycle of poverty.

Aroles believed that health is beyond medicine and they believed that health could be an entering wedged into total socio-economic development. They believed and demonstrated that the very poor have a great capacity for change and can effectively take positions of leadership if given a chance and support. Aroles have learnt the following principles while working in Jamkhed. Perhaps we may follow them if we wish to emulate Jamkhed model.

• The perceptions of poor and marginalised people are different from those of the elite and educated.
• It is not hard technology but often social action that improves health.
• The input of social sciences in primary healthcare must be emphasised.
• Health education should be related to the resources and culture.
• Rural communities are capable of planning and maintaining their own health.
• Medicine needs to be demystified and knowledge should be shared freely with people so that they can attain and maintain good health.
• Self-confidence must be promoted at all levels of the health team.

(ii) Child-in-Need Institute 24 – Parganas District, West Bengal.

Ans.   Through its field programmes, training and research, the focus has always been on health of women and children, child nutrition and development, adolescent issues and mainstreaming street children through education. In 1998, CINI was recognised as a National Mother NGO, under the Reproductive and Child Health (RCH) programme by the Ministry of Health and Family Welfare, Government of India.

CINI is famous for its Thursday morning clinic at Daulatpur. It has become a familiar fact of life for the people of the area. Services are provided for growth monitoring, treatment of common childhood diseases and preventive measures like immunisation, health and nutrition education.

Over many years, hundreds of women and children coming from long distances have been served. The biggest tribute to CINI’s work is that, these poor women endure the inconvenience of travel and time lost in order to bring their children regularly to a centre where they know they will be served. The emergency ward and nutrition rehabilitation centre, receive admission from distant villages and slums. About 700-800 cases are admitted each year.

CINI believes that the role of voluntary organisations is essentially to come out with innovative approaches and to support the government’s large programmes. CINI developed close links over the years with the state and central governments to avoid over centralisation in planning and implementing government programmes at the field level. Some of the collaborative programmes include:

• Assistance from state government to assist in flood relief operations and train Sishu Kalyans.
• The state government relies on CINI to handle all the training aspects for all their anganwadi workers and supervisors of the ICDS programmes.
• Implementation of National Smokeless, Chullah Programme and Rural Landless Employment Gurantee scheme of the government of India.
• Loan distribution under fisheries and farm activity development.

Medium Answer Questions                                                                        

Attempt any Two the following:

Q1. Discuss the role of Primary Health Centre in rural health care services.

Ans.   The programme of establishing primary health centres and sub centres with 4 to 6 beds at each PHC in a community development block having a population of 60,000 to 80,000 was launched as an integral part of the community development programme in the year 1952.

Structure and Functions: It should be centrally located in an easily accessible area. The area chosen should have facilities for electricity, all weather road communication, adequate water supply and telephone. At a place, where a PHC is already located, another health centre/SC should not be established to avoid the wastage of human resources. PHC should be away from garbage collection, cattle shed, water logging area, etc. PHC shall have proper boundary wall and gate.

The Chief Medical Officer in the district is responsible for organising all health activities in the district. Each district is covered by 8-12 PHCs. Under each PHC, there are about 8-10 sub-centres. With the implementation of the Multi-purpose Workers Scheme and the Community Health Volunteer Scheme, the Community Health Volunteer serves population of 1000. The male and female Multi-Purpose Worker has the responsibility of providing services to a population of 5000 to 10,000. The two MPWs are located in the sub-center. The Medical Officer has the overall responsibility of the block with a population of 80,000 to 1,00,000. One or two additional medical officers may be available to provide support. Male and female Health Assistant, a Sanitary Inspector and a Block Extension Educator act as the supervisors of the field staff. The key functions of PHC are given below:

• Medical care
• Mother and Child Care including family planning
• Safe water and basic sanitation
• Prevention and Control of local endemic diseases
• Collection and reporting of vital statistics
• Health education
• Referral services
• Implementation of national health programmes
• Training of health guides, health workers, health assistants and local dais

Inclusion of primary healthcare in the Twenty Point Programme started a new phase in rural healthcare in the eighties. This programme envisaged: acceleration of healthcare activities for the Scheduled Tribes and Scheduled Castes, further strengthening of MPW scheme and CHV Scheme and upgradation of existing PHCs into Community Health Centres (CHCs) and establishment of new PHCs for every 30,000 population by adding extra field staff to the sub-centre or by opening new PHCs. It was proposed to increase the number of PHCs by reducing the population covered by them from 80,000–1,00,000 to 30,000. The main feature of a Community Health Centre (CHC) or an upgraded PHC is a 30-bed hospital. It is provided with all specialist services.

The staffing pattern has also undergone changes from the earlier one. The staffing pattern in the new PHC is: Medical Officer, Community Health Officer (for public health), a pharmacist, two persons for secretarial work and four supporting staff. In the CHC, the staffing pattern is:

(1)      Four Specialists (Surgeon, Gynaecologist, Paediatrician)

(2)      Three general duty medical officers (public health, anesthetist, one from indigenous system of medicine)

(3)      Eight nurses

(4)      Two pharmacists

(5)      Two Laboratory technicians

(6)      One x-ray technician

(7)      One extension educator

(8)      One opthalmic assistant

(9)      Sixteen ward staff, and

(10)    Ten other ward staff.

Q2. Describe the major steps involved in the management of epidemics.

Ans:- The steps involved in epidemic investigation are as follows:

(i)        Verification of diagnosis: Sometimes reports of epidemic may be spurious. Therefore, the first step is verification of diagnosis on the spot, as quickly as possible.

(ii)       Confirmation of the existence of an epidemic: After confirming the diagnosis of the disease, the number of cases occurring is compared to the usual frequency of occurrence of cases in the area during the same period of the year. Often the existence of an epidemic is required no such comparison. At this stage, notification of the epidemic is done to the district health officer.

(iii)     Defining the population at risk: This is done by a quick enumeration of people at risk. This can also be estimated from existing census records. A map of the area is also obtained or prepared showing important landmarks, streets, colonies, dwelling unit, water sources, etc.

(iv)     Rapid search of all cases and their characters: Search and identification of cases should be carried on every day. Each patient or his/her relatives are asked a set of questions. The format of recording information from each case is designed. This format is known as the “case interview form” or the “epidemiological case sheet”.

(v)       Evaluation of ecological factors: Ecological factors that have made the epidemic possible should be investigated such as movement of human populations, atmospheric changes, breakdown in the water supply system, floods, etc.

Q3. Discuss the main stages in the implementation of Rural Health Care Programmes.

Ans.   The process of implementation has four functions which are given below:

(1) Co-ordination of activities: Implementation is nothing but the execution of the planned activities as activities form the backbone of any programme. In a programme, there are many activities to be implemented but the result of these activities cannot be achieved if they are not coordinated. Coordinate implies that “the process of bringing the activities of different persons into relation with one another so as to achieve a common goal.”

(2) Deployment of personnel: No activity can be implemented without deployment of the required personnel. In every plan, the requirement of manpower is mentioned. Deployment means:

(i)       Organising work: It means assigning specific tasks to each staff, setting procedures for holding staff meeting periodically to resolve issues of implementation and assisting the staff to perform their assigned tasks through in service training programmes. Job description, duty roasters and operating procedures are the tools for facilitating of this process.

(ii)      Direction of personnel: Assigning specific job without authority is meaningless. Everyone involved in the programme must be given some authority to undertake specific tasks as this will avoid duplication of efforts and claiming credit for the task performed by someone else and prevent avoidance of performing tasks. It also includes who will report to whom, the duration of control over staff and providing incentives to encourage participation and performance.

(iii)    Supervision of personnel: Some of the important functions of supervision are (a) applying strictly the agreed work standards, (b) specifying procedures for appraisal of staff members, (c) training need assessment of the staff, and (d) supporting staff in implementation of their tasks, team building and conflict resolution.

(3) Allocation of Resources: Needless to state that without resources no programme can be implemented. The resources, apart from human resources include, finance, material and other infrastructures such as building, land, etc. Allocation of such resources means ensuring availability, access, control over consumption and use, maintaining quality and inventory and disposal of the unwanted materials.

(4) Information Management: Information is vital to healthcare programme. Not only does this help the health team to know the health status of the community, but also to plan for improving the health status. Some of the critical indicators of health, such as IMR, MMR, and rate of disease prevalence can be assessed only if we have proper information system.

Short Answer Questions

Write short notes on any Five of the following:

1. Socio-Cultural Approach to Health

Ans:- According to this approach, the factors determining health are not merely the diseases and the availability of medicines to cure them, but the socio-cultural milieu in which the diseases occur on individuals and communities. Socio-cultural approach has two views:

(i)       The positive view is that people have historically evolved certain healthcare practices to deal with their health problems effectively. For example, the application of traditional medicines such as Ayurvedic, Siddha and Unani, to prevent and cure certain diseases. These practices are rooted in the cultural fabric of people and the environment in which they live.

(ii)      The negative view is that the ignorance of people and therefore they are diseased. Though factors such as illiteracy, superstitious beliefs do lead to ill-health, we cannot blame the people alone for their illiteracy and superstitious beliefs and practices. Such factors are deeply rooted in poverty and unjust social order. If there are no schools and teachers and if the people do not get even one meal a day, it is unrealistic to expect them to be literate enough to take care of their health.

2. Epidemiology Triad

Ans:- Epidemiology Triad: The Epidemiology Triad is a model of how an infectious disease is spread. It consists of an agent, a host and an environment. The agent is the organism such as a virus or a parasite that does the infection. The host is the organism that is being infected by the agent. The environment is the place and correct conditions for the agent and to come together with the host. There are several factors relating to the host and the environment, which are important to determine whether or not disease will occur in a host who is exposed interaction to the agent.

For example, tuberculosis is caused by the microbe Mycobacterium tuberculosis. This is the agent of tuberculosis and humans are the host. The agent of tuberculosis is necessary but not a sufficient condition for the occurrence of the disease. The interaction between the agent and the host is mediated largely by socio–economic, political and environmental factors.

3. The Cuban Model of Health Care

Ans:- The Cuban Model of Healthcare: The Cuban experience in healthcare provision stands as a contrast to the European and American models. The provision of free healthcare to all its citizens was an important part of the agenda of the socialist revolution there. In its 1975 Constitution, healthcare was codified as a right of all and a responsibility of the State. The socialist ideology has permeated its domestic and international health policies. The policies try to encourage informal doctor–patient relationships and creative use of health education (health education talks in the waiting rooms, etc.) The linkage between the ideology and health services is further underlined when the doctors are often called as health gorillas waging war on disease.

Cuba is often cited as a successful example of combining primary healthcare and specialist services. Since the approach is an integrated one, there is efficient use of resources with minor ailments being treated at the primary and secondary levels while the tertiary level deals only with cases requiring specialist care. The government’s commitment to the overall well-being of its people is reflected in the fact that curative services are not only free to all but there is equal emphasis on the preventive component.

4. Polio Eradication

Ans.   Eradication of polio is to be achieved by 2000 AD. The western hemisphere has already eradicated polio. According to the recommendations of WHO and experiences of countries which have eradicated polio, the following strategies have been worked out for polio eradication in India.

(a)      Strengthening of routine polio immunisation as done under the National Immunisation Programme, the emphasis being on increasing coverage to above 80 per cent of infants in all parts of the country.

(b)      Carrying out extra rounds of immunisation (“mop up rounds”) in areas where cases have been occurring in the previous years.

(c)      Holding of National Immunisation Days (Pulse Polio) where all children below 3 years of age are given polio vaccine of the same day throughout the country. The vaccination is done on 2 days every year separated by 4 to 8 weeks. It is usually held in winter season when transmission of polio is the lowest.

(d)      Having a sensitive surveillance system to detect polio cases. On detection of a polio case, all children below 3 years in the locality are given a dose of polio vaccine. This is known as containment immunisation.

5. Immunization

Ans:- Prior to 1985 immunisation activities were implemented as the Expanded Programme of Immunisation (EPI) but the coverage levels achieved till 1985 were only about 20-40 per cent because the implementation of the programme lacked the thrust and support required to achieve high coverage levels within a limited time frame. In 1986, the Universal Immunisation Programme (UIP) was started and it was considered as one of the technology missions of the government of India. At the inception of this programme, in 1985-85, vaccine coverage levels ranged between 29 per cent (for BCG) and 41 per cent (for DPT) but by 1997-98 the coverage levels have been 96 per cent and 90 per cent respectively.

The Universal Immunisation coverage of 27 million pregnant women and 25 million infants, annually, is one of the most important interventions under the Child Survival and Safe Motherhood Programme.

6. Community Diagnosis

Ans:- Community health diagnosis defined as determining the pattern of health problems in a community, including factors which influence this pattern. Often well conceived and carefully planned healthcare programmes fail even before they take off because of viewing health problems in isolation from other critical issues largely influencing the lives of the people. Therefore, having identified the potential community, for healthcare interventions, it is inevitable to analyse the community, particularly its structures and functions. In the following table, there are some of the suggestive information to be collected for community diagnosis.

Table 3.1: Information to be collected for community diagnosis

7. Health Information System

Ans.   The term health information system (HIS) refers to a coherent set of information about sick and healthy people used for specific purposes, such as treatment, preventive care, medical research, health evaluation and medical and financial management of the system. Health information systems must be coherent if a number of health objectives are be reached which will make it possible to achieve an overall, unified healthcare system in line with the concept of health put forward by the World Health Organisation.

There are many definitions used to explain the meaning of health information system. We may perhaps consider the following definitions:

“A mechanism for the collection analysis and distribution (dissemination) of health statistical information required to enable health planners to assess priorities, and to assist them in deciding how to meet particular priority needs and finally to enable health administrators to measure their achievement” (WHO/EURO-(1971 Information Health Statistics, Third European conference).

8. Principles of Health Education

Ans:- Principles of health education are as follows:

(1)       Selection of High Priority Target Groups at Risk: The selection of target groups in a community which are at high risk is important in order to identify their specific needs and plan an appropriate strategy to reach them within available resources. In a rural community, this selection will not only depend on project objectives but also on the social structure, problems and needs of each group.

(2)       Community Involvement: Health education is not the pouring down of information but an opportunity for community dialogue, reflection and analysis of past experiences in order to take decisions to solve problems and promote health behaviour.

(3)       Community Culture and Leadership: The design of health education programme must take into consideration of the nature of existing customs, traditions and culture within communities. The selection of family members and community within the at-risk population to promote active leadership in the health education process is important. It is also important to determine which community leaders–political, religious, traditional healers, school teachers, health workers, etc. influence decisions affecting health, nutrition or fertility.   Community