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reportreport 5-6 March 1998
Surat, India

Understanding Health Care Systems

The Centre for Social Studies (CSS) at Surat organized an International Workshop on Understanding Health Care Systems with special focus on Malaria. It was sponsored by the British Government's Department of International Development and the British Council Division (New Delhi) and prepared by Dr Lobo (CSS) attached to the Malaria Control and Research Project being conducted in the Surat District.

By Jan Brouwer

The objectives of this workshop were to share the findings of a two-year long study by the Centre on community perceptions of malaria and local knowledge systems regarding health; to draw out clear messages for information and education for mobilizing people for health awareness, and the training of the health personnel; and to contribute to the development of culturally appropriate health interventions. The deliberations were centred on three themes: (a) community health needs, perceptions, and initiatives; (b) the state: health agenda, perspectives, and action; and (c) health care delivery: indigenous healers and private doctors.
In Prof. Kothari's keynote address one question stood central: why have the objectives of the National Malaria Eradication Programme not been achieved after so many years? He believes this was because the programme was unilaterally based on providing allopathic health care by outside doctors through infrastructure such as the Primary Health Care (PHC) centres. The problem is not so much one of geographical distance between the PHC and the target group, but one of cultural distance. Prof. Kothari praised the sponsors of the project for standing open to the incorporation of the Indigenous Knowledge Component into the Project, so that the 'cultural gap' between the government provisions and the indigenous healer and that between the beneficiaries and the interventionists can be narrowed.
Sharon Wilkinson (British Council Division, New Delhi) attributed the decline in effectiveness of the National Malaria Eradication Programme to the lack of an integrated control strategy and the fact that people are still largely ignorant about the mosquito-malaria link. Therefore the medical-technical components of the project need to be supplemented by 'an ethnographic component covering knowledge, attitudes, practices and behaviour in relationship to fever, with a special focus on malaria'.

In a report session Dr Lobo concluded that 'a genuine understanding of the local habitat, culture, and values of people at village level is the only solution for making any intervention a success.' Hence people's behaviour as well as their conceptualizations and perceptions have to be included in the baseline for the design and implementation of any health care policy. Dr Rama Baru (JNU, New Delhi) expressed two worries about the report: the emphasis on the dichotomy bio-medical/traditional, and the absence of any insight into the perceptions of the interventionist. The discussion remained inconclusive about the problem of validation of traditional curing methods and the issue of intellectual property right of indigenous treatment procedures. The participants agreed that a perception study should include the perceptions of all stakeholders.
Dr Purendra Among Prasad's conclusions let loose a lively debate. He stated that indigenous health care covers a much wider field than modern health care and includes both the individual and the community; the physical and the mental, the social and the ritual domains. Whatever medical system(s) the patient consults, the traditional healers are always included; and there is a constraint relationship between the patient and PHC doctors. Dr Brouwer suggested that the structural position of the healer in the local community has to be identified prior to any intervention taking place. As the healer serves all people in a locality we should not speak about the poorer sections but about the voiceless sections of society.
The participants agreed that the diverse types of healers have to be studied in more detail, looking closely at their relationship to social strata and the natural environment. Qualities such as the transfer of knowledge between healers and their capacity for innovation and adaptation have to be considered.

Indigenous knowledge
Dr Prasad opened the second day with a presentation on the Ethnography of PHCs. Among his conclusions were that (1) the state supports exclusively the modern system of medicine, ignoring the indigenous systems; and (2) although the PHC's success depends fully on the involvement of the local community, the effective utilization of local (human) resources is still to be operationalized.
The participants agreed that the project should divide its attention equally between indigenous and modern aspects, both horizontally and vertically. In this context Dr Michael Elmore-Meegam (International Community for the Relief of Starvation and Suffering, Kenya) stated that community participation needs to be the epicentre of a new interactional model in order to achieve the social sustainability of the intended interventions.
The concluding session, chaired by Mrs Padma Prakash (EPW, Mumbai), brought three points to the fore. First of all the ethnology of the target groups needs to be mapped out; second, the research methodology of the Indigenous Knowledge component needs to be refined on the basis of clearly stated definitions. Thirdly the modern concepts of health etc. and the perceptions of the state need to be detailed in order to promote a sound interface between people's health and governing structures.
The organizers should be congratulated for having brought together specialists from the medical and social sciences as well as representatives of the bureaucracy in a fairly unique workshop in which ethnography was allowed to take centre stage.
Dr Jan Brouwer is the Director of the Centre for Advanced Research on Indigenous Knowledge (CARIKS), in Mysore, India.

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