Challenges Faced in Providing Primordial Care, Central India

The All India Institute of Medical Sciences, Bhopal is one of the pioneer institutes of health care in India. As we aim at achieving Health for all, we have to shift from medical care to health care. For achieving, it was crucial to have good rapport with the community. Therefore, we organized different awareness, generating activities among the local community. We faced various challenges and learned from them for the future activities in the community. We learned the importance of being a care manager rather than physician only to achieve health in all aspects. Our real time experiences in community and family health can help the new emerging health professional to provide more efficient health care.


Introduction
After India's independence, it was Jawaharlal Nehru's, first prime minister, dream to make medical excellence centre in India that would set the pace for medical education and research in Southeast Asia. The Bhore Committee in 1946 had recommended the establishment of a national medical centre. The All India Institute of Medical Sciences (AIIMS), New Delhi established in 1956 under the Colombo plan. It is an autonomous institution through an Act of Parliament; to serve as a pioneer institute in all aspects of health care [1]. Keeping AIIMS, Delhi as a model of excellence in health care the Ministry of Health and Family Welfare, Government of India under the Pradhan Mantri Swasthya Suraksha Yojna, established other six AIIMS like institute. AIIMS Bhopal is one of the AIIMS like health care institute [2].
The Department of Community and Family medicine has Centre for Urban Health AIIMS (CUHA) and Centre for Rural Health AIIMS (CRHA), as intensive field practice area. The CUHA situated at Banganga 10 Km away from AIIMS Bhopal caters mainly for population from slums and low socioeconomic class. The CRHA located at Chiklod Kala, 40 Km away from AIIMS Bhopal belongs to Raisen district. The Centre caters for nearly 60 villages. We in collaboration with state government deliver the medical care to the community. To shift from medical care to health care it was important to start various community-based activities. It was important to be a care manager rather than physician only to achieve health in all aspects. For care manager, it was advisable to interact with the community and understand its needs [3]. As the Ministry of Health and Family Welfare, India celebrates different public health activities [4]. We took this opportunity and plan to organize National Nutrition week, International youth day and others in our intensive field practice area. We aim at to communicate with the people from the local community along with generation of awareness about various common health problems.

Methodology
This was a community-based activity conducted in Banganga slums and Chiklod Kala AIIMS Bhopal, Madhya Pradesh, India. The team comprises of three doctors, three medical social service officers, and two attendants. The detailed proposal was prepared and necessary permission obtained from the concerned authorities. The Medical social service officers informed people of the community prior to the activities both verbally and written by house-to-house visits. All the activities were principally health education based by means of health talk, banners, filler, demonstrations, pamphlets, and other reading material.

Pre event
Our administrative experience started with submission of the project proposal. Though there was reluctance on the part of some officers, the head of the department was enthusiastic and granted full support. Financial constraints are particularly most critical in innovative activities [5]. Despite of being a premium institute we faced difficulties in financial arrangements. In community-based activities, arranging infrastructure is a mega exercise [6]. Availability, accessibility, and acceptability were the foremost hindrance in finding the place for conducting the activity. We met the infrastructure challenge with public private partnership. In Banganga slums, we got collaboration from the non-government organization, but in rural, it remained the major obstacle. Initially we finalize a government school in the local village for carrying out the activities. Unfortunately, it had to cancel just before the activity due to demise in the village. Finally, the activity was organized in an open space on top of a hill near to a temple on a local festive day. There was no cover or carpet provided for the activities due to poor finances. In addition, in the poor community people are always busy and occupied in agriculture or daily wages activities. It was therefore difficult to gather everyone to participate in the activity. High level of community participation is essential to bring obvious change in health status of the community. We consulted key stakeholders in the community before program finalization for suitable time. Thus, the place and time for the various community activities was decided. The next in line, was human resource planning. Most of the community activities are affected by shortage of manpower [7]. There was a scarcity of manpower in the department. We trained our human resources for maximizing efficient health care delivery process.
No structured pathway of establishing community contact to deliver a message was present. The participation from other doctors and students was not easily obtained due to lack of transport facility. Moreover, the lack of telephone network made the communication difficult among team members. Therefore, the health workers went door to door to invite the people to participate in the activity. The activity aimed at generating awareness regarding different aspects of health and nutrition. To make it visual a banner was required, which should be simple to understand and attractive. To be audible to the audience, one needs to amplify sound. But an amplifier requires electricity, which was not available. This proceeded to the distribution of refreshments to the audience. As we aim at promoting health, we come to a decision to distribute nutritious product like fruits rather than junk food. However, fruits are prone to be rotten. Any community-based activity is not useful if the health message fails to reach the masses, hence a press note had been sent to media.

Event
On the day of the activity all the members of the team actively participated, though there was a delay from the anticipated time schedule. On the site of the activity, shockingly not a single individual from the intensive field practice area was present. This clearly relieved that we are far away from the goal of health for all in our intensive field practice area, and we had not gained enough confidence of the community to involve them with us. In light of this worker were again sent to call on the people and a few of them turn around. Then we involved anganwadis and a large crowd gathered. The other nongovernmental organization and partners felt to have no interest other than publicity. Mainly children and women attended the activities. Due to lots of disturbance the vital message, met to be transferred to the community, was unsuccessful. Later the refreshments were stocked out. Moreover, people attended the activity, believing that it was a medical cure campaign rather than health talk. The activity ultimately completed except we could not comment on the achievement.

Discussion
We are living in an era of accelerating change. The old ways are rapidly becoming obsolete and new opportunities are coming up. The process of adoption of an Urban and Rural Health Centres are not time bound and given less preference than developing clinical and curative department in a newly establishing medical institution. We can notice the AIIMS, New Delhi started in 1956 whereas the Comprehensive rural health service project started nearly 10 years later. The peripheral centres linked with medical colleges must be started along with the college and hospital of a newly establishing medical institution along with clearly defined timelines of activities and adequate funds and facilities.
There is no efficient structured pathway to deliver a health message to the community. There is a need to develop coordinated, convenient structured pathway to deliver a message to the masses. The target population usually belongs to low socioeconomic status. They resist participating in health promotion activities in the community due to loss of wages. These activities should be planned in such a manner to avoid loss of wages or agricultural activities. The majority of areas do not have road, transportation facility, and rely mainly on walking, motorcycle, and scarcely public transport. We need to have good connectivity and public transport, which helps in accessing health care. Nevertheless, the strong team network should be present for efficient utilization of the scarce human resources. The work force in any central institute is usually representative of various parts of India. For the local community it is difficult to accept people from outside, speaking a language, which differs from their own especially in tribal habitations. Therefore, one should approach the government machineries in first stance in addition to individuals.
In India, as in other developing countries, people still not recognized the importance of preventive care and continued to favour curative services in a Hospital. The same concept of preferring curative medical services to preventive medical services exists in our Urban as well as Rural Health Centres. The Department of Community and Family Medicine challenged to reverse the concept in the near future, promoting mainly preventive medical care along with curative services. This certainly needs the transformation of the physician to the care managers. We are still searching for an appropriate method of interventions and health activities in the community. The public health had changed in recent years to improve the scientific standards for evidence underlying interventions and actions. However, the traditional study designs may not fit to evaluate its day-to-day community activities and without evaluating its activities, we cannot generate evidence.

Conclusion and Recommendations
These activities provided us with the opportunity to interact with the community. We recognized the need of care managers in the community. Thus, we conclude that with health care managers, we expect to have substantial gain in health of the people (Figure 1). We also recommend that all public health professionals should document their real time experiences as for the new public health professional their experiences can be a boon in disguise.