A comprehensive baseline survey was undertaken in two contiguous districts of Salem and South Arcot of Tamil Nadu for strengthening the health and family welfare services with the assistance of the Danish International Development Agency (DANIDA). The main objectives of the study were to obtain data on the prevailing health status of population, the village organisations and leadership in health matters and important aspects of the health system of the area, such as Primary Health Centre (PHC), Medical Officer (MO) and para medical personnel identified as field health workers.

a) Medical Officers: A questionnaire was canvassed by post mainly in June/July 1982 after briefing the Medical Officers at their monthly meetings at Health Unit Districts. Out of 221 posts of Medical Officers (MOs) in 72 Primary Health Centres (PHCs), 68 were vacant. Of the 153 MOs in position, replies were received from 119 (78%), 69 in Salem and 50 in South Arcot. Among these MOs, 87 were men and 31 women, and 71% were in the age group 30-39 years. Proportions of married were 87% in men and 71% in women. Of the 119 MOs, 111 were qualified in allopathic system of medicine. Though 52% stated that they had training in rural health services, only 26% mentioned that they were trained at Health & Family Welfare Training Centres (HFTC). About 50% of MOs had total work experience in Health Department of 1-4 years and 25% of 5-8 years. Of the average service of 4.62 years in this department, 3.09 years were in the PHCs where they were working at the time of the survey. The overall ranking of functions of MOs was 1) curative (60.5%), 2) Preventive (41.2%), 3) Promotive (23.5%), 4) Supervision (35.3%) and (5) & (6) Public relations (23.5% and 41.2% respectively). Administration had the highest percentage for 2nd and 4th rank. MOs trained in rural health, however, had given more importance to working with block officials as compared to other MOs. Though nearly 75% MOs had stated that they plan a weekly schedule of work, while giving the detailed schedule, a maximum of 48 MOs had included outpatient clinic on any day of the week and the position with regard to important managerial functions and rural services was much worse. About one third did not conduct any mobile clinic during the month prior to the survey; 28% did not answer the question and the remaining 40% had conducted 2 or more clinics. Most of them have provided curative treatment and not promotive or preventive services. About 43% stated that there were no voluntary organisations working in their area and more than 80% of MOs stated that private medical practitioners did not take any help from them. About 50% said that neither the private practitioners nor voluntary organisations participated in the health activities i.e., immunisation, health camps and family planning, conducted in the villages. About 22% stated that villagers did not participate in the health activities. While 23% had no difficulty in working at PHCs, 30% mentioned lack of facilities at PHC, 18% each stated personal problems, heavy work load/lack of staff and more administrative work and 16% transport problem. About 30% mentioned that there were no problems, 44% mentioned staff vacancies, 24% lack of cooperation from staff and 14% staff changes. While 47% found no advantage in working in a PHC, 27% mentioned about provision of better services to the rural areas, 18% about better understanding of basic health problems and 8% wider experience including management. About one third only gave the relevant suggestions for improvement of the centres. The MOs at PHCs can play a crucial role in the delivery of health services in rural areas. They are the leaders of the health team at the grass root level with adequate technical knowledge and a very high degree of acceptability. The findings of the present study are therefore, very valuable and the shortfalls and deficiencies listed below have to be given adequate attention: i) All posts of MOs and staff to be filled. ii) Provision of facilities to staff at PHC. iii) MOs should give more attention to public health activities. iv) Adequate supervision of work of MOs and special training to them in rural health.

b) Primary Health Centre: In the rural areas, Primary Health Centre (PHC) is the nerve centre of the health services both institutional and community oriented. It was planned to obtain some basic data on the organisational structure, area of responsibility and functioning of PHCs and utilisation by the people of the services provided by PHCs. All the 72 PHCs in the project area were studied through a questionnaire cum interview schedule. Further, data and clarifications were obtained through interviews from the Medical Officer In charge of PHC and knowledgeable staff such as Health Inspector (General) and Block Extension Educator. The data were collected during June 1983 to January 1984. The area of coverage of 82% of PHCs was within 300 sq. kms., 194 sq.kms in Salem (District I) and 237 sq.kms in South Arcot (District II). Thus, PHCs in South Arcot generally covered more area and more villages and served larger populations. About half of the PHCs could not provide information on scheduled caste and scheduled tribe populations who are part of the target population under the project. Out of 1175 sub centres for which information was available, 72% were within 20 kms. of PHC. This was so for 84% of 548 sub centres in District I but only for 62% of 637 sub centres in District II. The average distance of sub centres from PHC was 12.3 kms. in District I, 18.4 kms (one and a half times) in District II and 15.7 kms at project level. Organisation: The average number of villages per sub centre was almost the same in both districts (3.3 and 3.4). A sub centre covered an average population of 4,800. All but two PHCs were in standard building and all were electrified. Nearly half of the PHCs were located outside the village after which it was named. No other medical facility was available within one kilometer reach in 40% of PHCs in District I and 70% in PHCs in District II. Vacant posts were more among Medical Officers (37.6%) and Medical Officers (indigenous) (36.4) and less among para medicals (16% among supervisors and 10% among workers). While about one third of the PHCs did not have separate laboratory, about half did not have separate injection/dressing room and Minor OT. While most of the PHCs had refrigerator and microscope, 77% of the former and 93% of the latter were in working order. Functions: The main training activities of PHCs were Dais Training & Orientation Training Camps for which the average number of courses per PHC during the year prior to the survey were 3.1 and 2.6 respectively. Health education activities were mainly confined to group meetings and distribution of publicity material, with average annual performance of 70.3 and 53.8 respectively. Average outpatient attendance per PHC during the previous year was about 36,500 of which 19,600 were new outpatients. On an average, 98 patients were admitted in beds in a PHC (120 in District I and 71 in District II). For all the MCH activities except distribution of iron and folic acid to women and giving polio vaccine to children, District II had fared much better than District I. While for the other two activities mentioned above District I fared better. There was no uniformity between PHCs and districts in the number of tablets of iron and folic acid given per woman. Tuberculosis : The average percentage of persons with symptoms of TB was 1.8 (2.1 in District I and 1.5 in District II) as compared to the expected rate of 2.6% based on a study by the NTI. Identification of symptomatics from new out patients is on the low side, particularly in District II. As against the expected positivity rate of 10% among sputum smears examined, the rate was 14.4% (8.1% in District I and 21.4% in District II). The reason for such differences need to be studied in depth. Leprosy : Since leprosy work is carried out by special teams, most of the PHCs are not aware of the work done in their areas. Malaria : The average rate of fever cases identified per 1000 population during the month prior to the survey were 8.1% and 15.7% respectively. The figures for blood smears made were almost the same. The average number of persons given anti malarial drugs (mostly chloroquine) per 1000 population were 8.0 in District I and 20.7 in District II. Chlorination : In District I where a PHC covered an average of 51 villages, 84 wells were chlorinated during the month prior to the survey. The corresponding figures for District II were 111 villages and 89 wells chlorinated per PHC. Registration of births & deaths : The birth rate on the basis of births recorded by PHCs was 13.3 per 1000 which is less than half of the birth rate for Tamil Nadu for 1983. The recorded death rate was 8.3 per 1000 as compared to an expected death rate of 11.5. Recording of births and deaths needs considerable improvement in almost all PHCs. Referral : Among 64 PHCs who gave information on referral of patients for tertiary care, 21 referred to one hospital, 34 to either of two hospitals and 9 to anyone of three hospitals. Records & Reports : Surprisingly, PHCs gave a wide range of answers about the records and reports they maintain. Though there is a general complaint that records and reports are too many, there were hardly any useful suggestions about which records and reports could be simplified and reduced. Targets : Another surprising finding is that there was no unanimity in the answers from PHCs about the units of period for achieving targets under national programmes. Supervision : With regard to supervision of non- medical staff at PHC there was no uniform pattern. Medical Officers carry out field visits mainly for either control of epidemics or to pay surprise checks. Collaboration : Most of the PHCs did not seek collaboration of other Government departments, voluntary organisations or community leaders. The limited collaboration sought was mainly for Family Welfare Programme. Only about 60% of PHCs felt that the community can participate in Immunization, 52% in Family Welfare and 15% in Epidemic Control. Most frequent illness : Conditions affecting digestive and excretory systems were mentioned as the most frequent illness in their area by 38 out of 68 PHCs, followed by conditions affecting respiratory system by 32 PHCs, pyrexia of unknown origin by 20 PHCs, and skin diseases by 14 PHCs. Health problems : When asked about the health problems in villages, replies from PHCs dealt with diseases (illness) problems only.

The main weakness of the PHCs was observed with regard to management, inter departmental collaboration and community involvement as reiterated below: At least 40% of PHCs did not have 1981 census figures for population. Further, about half of them did not have population figures for scheduled castes and scheduled tribes. Recording of births and deaths are far from complete. Further, there is considerable indifference towards maintenance of all records and reports. The Medical Officers In charge, do not supervise the other Medical Officers of PHCs. Their knowledge about functions of para medical staff was inadequate. Under these circumstances neither could the Medical Officer In charge ensure adequate and proper supervision by the para medical supervisors nor guide them in their work. Acute shortages of Vitamin "A" and general medicines were reported. So also for mass media equipments such as film projector and sound system. Collaboration with other departments and voluntary organisations was quite weak. Contacts with community leaders either to understand the health problems as conceived by them or to seek the co-operation of the community were also at a low ebb. IUD insertions which benefit the younger couples or those with small families were quite negligible and the stress was on sterilisation only which benefit mainly older couples or those with already large families. Health education activity of PHCs was at a very low ebb.

c) Field Health Worker : The field health workers who consists of Health Workers (HWs) and Health Supervisors (HSs) were identified as important para medical workers. They play the most crucial role as they have daily contact with the rural population in their homes. The main objectives were to obtain a profile of field workers, to ascertain the area of responsibility, health services rendered by them, community responsibilities and supervisory functions of the HSs. The information was collected through pretested interview schedule. Of the 326 HSs and 2349 HWs in position, 165 were interviewed. The majority of male HWs were of age 30-39 years, while female HWs were of age 20-29 years. All the HSs and all but one of the male HWs were married. Among female HWs, half were married and about 88% of female HSs were married. Vast majority of HWs and HSs had education upto secondary level. The pattern with respect to these profiles was similar in both the districts. Of the male HWs 65% and of the female 32% had training in multi purpose work. While 83% of male HSs and 45.5% of female HSs had multi purpose work training, supervisory training was received by only 1.8% of male HSs and 9.1% of female HSs. With regard to total experience in the health and family welfare department, male HWs had more experience than female HWs. The difference was even bigger in average years and experience between male and female HSs. On an average, 6 villages were allotted to male HW and 4 to female HS, a male HW had to cover an average of 2291 families as compared to 1014 for a female HW. On an average, HW had to travel 6.8 kms to cover the villages allotted. The male HWs approached the villages by cycle or walk while female HWs by walk and bus. Availability of trained dais in the villages was reported by 40.9% of HW(F)s as compared to 50% of HW(M)s. Similarly, according to them about half of the villages have community leaders. Contact of HWs with such bodies need improvement. To the question on number of patients attending SHC services, 80% did not give an answer. The average attendance by HW(F)s was 7. Services given by HWs in villages allotted were malaria, FP & HE. The services received lower priority were TB, environmental sanitation, school health and registration of births and deaths. While 76.3% of HW(F)s maintained that they have a weekly schedule, only 46% of HW(M)s have weekly schedule. On an average during a month HW(F)s worked for 22.4 hrs and HW(M)s for 23.0 hrs in the village. On an average, 12 households are covered per hour. About three fourths of HW(M)s stated that they carried paracetamol to the village, 19.2% sulpha guanidine and 15.4% chloroqine. Among HW(F)s, 76.3% carried anti anemic drugs, 68.4% multi vitamin tabs and 47.3% anti malaria drugs. No medicine was carried by 44.3% of HS(M)s, and 24.2% by HS(F)s. Only 54% of HW(M)s and 74% of HW(F)s mentioned that they provided family planning services in the villages. Supervision of FP work by HSs is also very poor. Few HWs and HSs carried nirodh, oral pills or FP register when they visited the villages. Complaints that the high target for FP hampered health activities appears to be a cover up only. About 45% to 69% of health workers and supervisors said that TB work was not applicable to them. Similarly 42% to 50% also mentioned that nothing to be done for diagnosis of leprosy. Regarding the aspect of their work which are supervised by their supervisors, many did not reply and the others gave a variety of isolated answers. There is urgent need to give training to medical officers and health supervisors on how to carry regular qualitative supervision. The HWs make frequent visits to PHCs, some of them going once a week. This may interfere with the actual work in sub centres.

d) Trained Birth Attendant : In spite of the request to the PHC staff and village leaders to ensure that the trained dais of the selected villages were present, only 24 out of the 80 Dais were present during the survey. They were interviewed. About 54% of them belonged to families in which women attended to births by tradition. About 63% were illiterate, 29% had a monthly income of Rs.100/ or more. Fifteen belonged to backward classes seven to SC one each to ST & Christianity. Two thirds were trained before project started. Over 90% had experience of 5 years or more. Only two thirds of the trained dais have received the kits and less than half had received practical training in conducting deliveries. Different aspects of ante natal care were mentioned as follows: 82% periodical check up, 59% tetanus toxoid and 46% iron and folic acid. The number of deliveries conducted by trained dais was the same as before and after training. Majority of dais do not report births to health personnel. About 75% of the trained dais had referred at least one woman for delivery to ANM or hospital during the previous month. Eleven of the 24 dais, had no difficulties in carrying out their work while an equal number mentioned inadequate regular income. Trained dais were mostly aware of ANMS but not of Basic Health Worker, Malaria Worker or Health Inspector. Neither educational status nor experience had any influence on the functioning and working pattern of the trained dais. There were equal number of untrained dais, it would be worthwhile to train them also. Dai is important liaison between PHC and village for child births, post-natal care, family planning and registration of birth. Some future thought had to be given about their regular income, providing of kits, the replenishment and supervision during frequent visits by Health Workers and Health Supervisors. This will go a long way in ensuring co-operation from trained dais and in boosting up the morale of these village level workers of low socio economic standing which will make them useful participants in grass root level health activity.

e) Village Appraisal : Appraisal of the villages with their multi sectoral needs and activities would provide a third dimension to the survey. An appraisal of sample villages was conducted along with the household survey during June-November 1983. The method of group discussion was adopted to collect the data for village appraisal. Group discussions were held separately for SC & ST so that they could express their views freely (Adi Dravida colonies). This report is based on the information collected through group discussions in 71 main villages and 35 Adi Dravida(AD) colonies. About 45% AD colonies did not generally avail of services at PHC and one fifth did not avail of any service from HWs. Most of the groups felt that allopathic doctors were accessible to them followed by homeopaths. Contrary to expectations accessibility to practitioners of Indian system was poor. ANMs were more accessible to main villages than AD colonies. More than three fourth of main villages and AD colonies stated accessibility of dais. Most of the general facilities were accessible to a large extent except community centre and library. One of the main source of water was pucca well for three fourths of people. About 40% mentioned kutcha open well or river/canel. Latrines were few. Open field was generally used. Both manure pits and scattering was used for disposal of refuse to a large extent. Nearly all let out sullage to open places. About 50% of the villages mentioned that there was no developmental activity during last 12 month period prior to this appraisal. The activities mentioned more frequently were mid day meal scheme, water supply, school building, road construction and health centre. Most of the villages were not aware of who had taken the initiative for these activities. About 10% stated that there were no TB & leprosy cases among them while most of them mentioned DTC, general hospital or PHC as source of treatment of TB. Major problem of the villages were lack of water, transport and communication. Others mentioned were facilities for treatment and for education. Participation of women and younger generation in the group discussion was more in AD colonies than in main villages. According to villagers fever was the most common illness, followed by gastro intestinal disorders, diseases of respiratory system and eye complaints. Main causes of ill health were lack of sanitation and protected water supply. The perceptions by villagers pointed out the need for not only improving the availability and accessibility of service facilities but also for educating the villagers about how these could be made use of. The bigger and most important gaps would appear to be the provision and/or utilisation of preventive and promotive services, in availing of treatment facilities at PHCs and in reporting of births and deaths. Community involvement in all development activities would lead to informed participation in all developmental activities.