Policies, Plans, and People: Foreign Aid and Health Development

4. Delivering Services to Rural Villages

4 Delivering Services to Rural Villages Because integration was being phased in during the late 1970s, health posts varied considerably in the range of services provided. Broadly speaking, they can be divided into three categories: nonintegrated, partially integrated, and fully integrated. Nonintegrated posts had not yet assumed any responsibilities from the vertical projects; they simply provided treatment for common illnesses. Partially integrated posts had assumed some vertical project responsibilities and had village health workers attached to them to provide outreach services. Fully integrated posts provided all services, including those formerly covered by the vertical projects. In 1978-79, Nepal had 533 health posts: 185 were nonintegrated, 283 were partially integrated, and 65 were fully integrated. Of Nepal's seventy-five districts, twentythree had either partially or fully integrated posts (American Public Health Association 1980:29). Health posts were organized by population and geographical area. In 1978, most served an average of 30,000 people, although ICHP plans called for 7,000 people to be served by each health post in mountainous areas, 13,000 in the hills, and 25,000 in the Terai. The Department of Health Services had further divided its most peripheral service area into veks, which averaged one and a half panchayats. (The term panchayat was applied not only to government councils but also to the primary political unit in Nepal, which averaged from 3,000 to 5,000 people.) Each health post served four to six veks; as integration proceeded, each vek ideally was assigned a village health worker (VHW), a paid ICHP employee who circulated from house to house gathering data on health status , identifying health problems, and encouraging villagers to seek care at the post. The VHWs were supervised at the post by the health assistant , a worker who treated patients and also managed all health post operations. The health assistant was supervised in turn by the health inspector from the district office. Nonintegrated posts had a health assistant but no VHWs. Partially integrated posts had at least a health assistant and some VHWs attached. Fully integrated posts had a number of additional staff members with various levels of paramedical training. All posts had at least one peon, the lowestranking worker, whose job was to do custodial work and run errands. To find out how the policies and plans developed at the international and national levels were affecting health care in Nepal's villages, I visited twenty-four health posts in ten districts during 1978-79—some fully integrated, some partially integrated, and some nonintegrated. My visits revealed that some posts were functioning more effectively than others , often owing to the efforts of exceptional health workers. All posts were struggling with a variety of common problems. Among the health posts I visited, Tate Health Post in District I (pseudonyms are used where possible, especially for health posts and districts) was one of the best. In 1979, it was in an early stage of integration, meaning that it was staffed by a health assistant and a peon, with three village health workers attached. It was expected to deal with A Partially Integrated Health Post DELIVERING SERVICES TO RURAL VILLAGES 83 all health-related problems except malaria surveillance, which was still carried out by the Malaria Eradication Program. Tate Health Post was located on a ridge at a 4,300-foot elevation on a main trail. To reach it I took a three-hour bus ride from Kathmandu, walked four hours along steep trails to District I headquarters, and then walked another four hours to the post. The health post and the local panchayat shared a three-room building, which the panchayat had constructed with mud and stones. A new building was being constructed for the post by the panchayat with voluntary labor. The Tate Post served about 19,000 people—7,000 people in Tate panchayat and 12,000 in two other panchayats. Most lived by subsistence farming; in the countryside surrounding the post, rice, corn, and wheat grew in terraced fields. The local population consisted of several castes and ethnic groups: Brahman, Chetri, Tamang, Gurung, Newar, and Magar. Each ethnic group spoke a different language, making it difficult for many patients to communicate with health workers. In this hilly area, some patients walked five hours to reach the post. Those who could not walk were carried in back-baskets or on stretchers. Tate was known as the best health post in the...