Dispensers in Health Care System

Unit: 1
Dispensers in the Health Care System

Learning Objectives
After completing unit 1 dispenser students will be able to:
a. define health, health promotion and gender
b. appreciate the general organization of the health care system and the health care delivery system
c. list out national and provincial priorities (MDGs) and understand government prescribed job description for dispenser
d. demonstrate skills required for effective communication.

Brainstorm
Ask students:
What is health?
How can people achieve health?
What is Pakistan’s health policy?
How is health care system organized?
What could a country do to keep its population healthy?
The Concept of Health
Definition of Health:
The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (WHO Constitution, 1948)
Thus, health “is a positive concept emphasizing social and personal resources as well as physical capabilities”.
Health as a Resource and a Basic Right
“Health is the extent to which an individual or group is able, on the one hand, to realize aspirations and satisfy needs and, on the other hand, to change or cope with the environment” (WHO Euro, 1984), is another version that supports and builds on the original WHO definition.
It presents HEALTH as a RESOURCE for everyday life and not an OBJECTIVE of living. It means that health acts as a driving force and an investment that enables us to aspire for greater things in life.
The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political beliefs, economic or social conditions.
WHO further recommends that governments have a responsibility for the health of their peoples that can only be fulfilled by the provision of adequate health and social measures. Therefore, many governments have included health as a basic right of their peoples in their national constitutions. Countries of South America such as Mexico and Paraguay accept health as a fundamental right of their citizens. This expression enables citizens of those countries demand health care provision as a fundamental right from their governments. And governments compulsorily have to keep health at the top of their policy agenda and provide resources accordingly.
Holistic View of Health
The way we feel about our health is very important. There is evidence that the way we perceive our level of health may be more important than true measures of health. Two aspects that shape our views about health are:
i. how we feel?
ii. how well we can function?
iii. How we feel:
Feeling well is related to our attitude as well as true measures of health. But it is all relative. In other words, individual perceptions of pain and limitations vary widely from person to person. People who feel well and have a positive attitude are more likely to actually be healthy as well.
iv. Ability to function:
The ability to carry out requirements for independent living can be another parameter for defining health. It may be difficult to feel healthy when we cannot function independently. However, once again, there are many cases of individuals learning to adapt to disabilities and functioning very well over time.
Thus, the state of our health reflects our ability to meet challenges of life and maintain our capacity for adequate functioning. This requires that different features of our makeup, i.e. mental, physical and biochemical, maintain a level of performance that influence and support each other in a positive way. Similarly, our interaction with our surroundings is equally important for maintaining our health.
If we develop a healthy lifestyle and maintain a positive outlook, we have the greatest opportunity to function at our best. Healthy lifestyle requires regular exercise, adequate rest, adopting a high level of personal hygiene, eating a nutritionally balanced diet, abstaining from the abuse of drugs, taking care of one’s mental well-being and developing social skills to interact in a positive manner within society. To be healthy is to be in a state of harmony (balance) with one’s surroundings. Health advice, when needed and preventive measures such as immunizations further boost our health. Furthermore, a healthy person has a duty to the health of fellow human beings and his or her surroundings.
Conversely, if we neglect our diet, body requirements and continuously view life through a negative lens, our health will start declining. This reduces the vitality and integrity of our mind and body. It will ultimately decrease our ability to function optimally. Thus, our ability to grasp the link between our physical, biochemical and emotional bodies is central to the understanding of the concept of health.
In a nutshell, health is a positive concept. It is related to how a person feels or what is the level of a person’s capacity to function to meet challenges of life. Health depends on a number of factors. Some of these factors are within the makeup of human body whilst some are outside in the surroundings.
Primary Health Care
Definition
According to the WHO Primary Health Care (PHC) is the essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford. It forms an integral part both of the country's health system of which it is the nucleus and of the overall social and economic development of the community.
It is a relatively new approach to health that was introduced after an international conference in the city of Alma Ata in Kazakhstan in 1978. WHO and UNICEF had organized the conference.

The conference declaration recommended that Primary Health Care should:
· reflect and evolve from the economic conditions and sociocultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience;
· address the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly;
· include at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs;
· involve, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors;
· require and promote maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate;
· be sustained by integrated, functional and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need;
· rely, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.
PHC is both a philosophy of health care and a model for providing health care services. However, its focus is on preventing disease and promoting health. The above 7 points could be summarized into the following 5 principles:
· Accessibility
· Community Participation
· Health Promotion including appropriate preventive and curative programs
· Appropriate Technology
· Inter-sectoral Collaboration
These five principles work together to contribute to the improvements in health of individuals, families and communities.
In Pakistan PHC relates to the professional health care received in the community, usually from a BHU or a dispensary. It covers a range of curative and preventative services, including health education, health promotion, counseling and curative treatment. Although Pakistan does not have a referral system, it has a chain of basic, secondary and tertiary health facilities which jointly form the primary health care system.
Government of Pakistan’s National Program for Family Planning and Primary Health Care takes care of the basic health needs of the rural communities. This is a community-based approach designed to address basic health problems of rural women and children and covers the entire country. Similarly, Expanded Program on Immunization (EPI), National Tuberculosis Control Program, National Aids Control Program, National Program for Prevention and Control of Hepatitis and National Maternal, Neonatal and Child Health (MNCH) are some of the PHC interventions launched by the Government of Pakistan.
Dispensers play a key role in the primary health care system. They are front line health care providers who frequently come in contact with health services clients. Their responsibility demands that they should check if their clients have knowledge of the different health care provisions such as EPI, NPFP&PHC and MNCH, and are using them as well. Creating awareness about health issues means empowering health care clients. Therefore, it is the responsibility of dispensers to counsel and advise their clients on how to make best use of health services.

Brainstorm
Ask students:
What is health promotion?
How can you promote health of people?
What is the role of health care provider in promoting health?

Health Promotion
What is Health Promotion?
· Health Promotion is the process of enabling people to have a better control over their health and its determinants that will ultimately lead to improvement of health.

· Health Promotion is a gender sensitive and pro poor approach as it is grounded in an understanding of economic and social determinants of health.

· Health promotion approach identifies that the health of people is affected by not only the genetic makeup but also some other factors including living and working conditions, personal habits, environmental factors and, social and cultural norms.
Ottawa Charter for Health Promotion (1986)
A conference in Ottawa, Canada in 1986 formulated a charter called the Ottawa Charter. It identifies three roles of a health promoter and five action areas for health promotion.
Three roles of a health promoter
· Advocacy for health
· Enabling all people to achieve their full health potential
· Mediating between different interests in society.
An “advocate” for health promotion is a person (man or woman) an organization or group which works for raising demand for favorable conditions for health such as political, economic, social, cultural, environmental, behavioral and biological factors.
An “enabler” is a person (man or woman), an organization or group that aims at reducing differences and gender inequalities in current health status and ensuring equal opportunities and resources to enable all people to achier their fullest health potential. An enabler works for supportive environment, access to information, life skills and opportunities for making healthy choices and have control over their life.
A “mediator” may be any actor or factor that contributes to mediate between differing interests in society for the pursuit of health. They may be government, non government organizations, health or other social and economic sector, local authorities, industry and media etc. The coordinated effort by all these factors may realize the ultimate goal of health promotion.
Priority Action Areas or Strategies for Health Promotion
Building healthy public policy
Health Promotion goes beyond the health care. It deals with putting health on the agenda of policy makers in all sectors and at all levels directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health.
Creating supportive environments
Health is linked and affected by other social, economic and developmental sectors. Health Promotion makes the living and working condition safe, satisfying and stimulating and enjoyable. The conservation of natural resources is also a global responsibility. Work and leisure should be a source of health for people.
Strengthening community action
Community empowerment is an important focus of health promotion approach. It ultimately develops in individuals and communities ownership and control of their endeavors and destinies. Community empowerment also includes developing flexible systems to strengthen public participation in the health matters and health services. This requires access to information, learning opportunities for health and funding support.
Developing personal skills
Enabling people to learn throughout their life is essential. It prepares them for all stages of life such as childhood, adolescence, middle-age, old age, motherhood, and parenthood etc. It also helps them cope with chronic illnesses and injuries. This has to be facilitated in school, home, work and community settings.
Action is required through educational, professional, commercial and voluntary bodies, and within the institutions themselves
Reorienting health services
Role of the health sector should move beyond providing clinical and curative services. It should adopt the direction of health promotion.

Major Health Promotion Strategies:
· Health education
· Health communication (please see section 10 of this unit)
· Community development
· Organizational development & change
· Healthy public policy
· Advocacy
· Inter-sectoral collaboration
· Self-help and mutual aid

Health Promotion in the Context of Government of Pakistan (GoP) Policy Documents
GoP policy documents especially PRSP (Poverty Reduction Strategy Paper) & MTDF (Mid Term Development Framework) and Health Sector Reform Program are very much in the favor of health promotion in the public health sector.

The Health Sector Vision for 2005-2010
A healthy population practicing a healthy life style with a sound health system which is effective, efficient and responsive to health needs of low socio economic groups especially women in the reproductive age.

National Health Policy (2001) Priorities and the Millennium Development Goals
Pakistan’s overall national vision for the health sector is based on "Health-For-ALL" approach. The Health Policy 2001 aims to implement the strategy of protecting people against hazardous diseases; of promoting public health; and of upgrading curative care facilities.
Ten Specific Areas of Reforms in Pakistan’s National Health policy 2001
· Reducing widespread prevalence of communicable diseases;
· Addressing inadequacies in primary/secondary health care services;
· Removing professional/managerial deficiencies in the District Health System;
· Promoting greater gender equity;
· Bridging basic nutrition gaps in the target-population;
· Correcting urban bias in health sector;
· Introducing required regulation in private medical sector;
· Creating Mass Awareness in Public Health matters;
· Effecting Improvements in the Drug Sector;
· Capacity-building for Health Policy Monitoring

Of the above 10 priority areas of the National Health Policy the dispenser has a direct role in:
· reduction of communicable diseases
· promotion of gender equity
· building community awareness and providing appropriate health education for prevention of disease.

Millennium Development Goals (2001)
Pakistan is a member of many international forums and associations for different purposes. The most noteworthy are the United Nations (UN), South Asian Association for Regional Cooperation (SAARC) and the ‘Commonwealth of Nations’. The Government of Pakistan is a signatory to many international charters and treaties that guide various sectoral policies and their role within the country as well as Pakistan’s role in the international scene.

The Millennium Development Goals (MDGs) are a part of an international treaty that Pakistan has signed. The MDGs address the critical human development issues of the present day world and if a country achieves these goals it is anticipated that the situation of human development will improve significantly to afford a dignified and comfortable life for all citizens of that country. The box below presents the MDGs.



As clearly visible Goals 4-6 are directly health-oriented, while Goals 1-3 are more general but address the social determinants of health as highlighted in the section on Health Promotion in this chapter. Goals 7 & 8 further address the confounding factors of poverty and under-development. Thus it will not be an overstatement that the UN MDGs are designed to promote health and ensure (if achieved) the enjoyment of full health potential of all especially protecting the rights of the poor and gender-disempowered sections of our society.

Our health policies and the system of health care are also being aligned to these MDGs and it is imperative that we remain mindful of these MDGs in our service provision. The most important message for the dispenser is to pay attention to the reduction of infant mortality, maternal health and prevention and control of HIV/AIDS, Malaria and other diseases. The dispenser can play a pivotal role in helping Pakistan achieve the MDGs especially by focusing on enhancing the understanding and improving the behavior of the communities to:
· prevent a huge proportion of infant mortality
· improve maternal health,
· prevent various communicable diseases
· enable provision and utilization of appropriate basic health care.

All of the above will need the dispenser to develop skills and knowledge that are presented in this textbook.
Introduction to the Health Care System
We are all familiar that the provision of health services to the community is done through various health facilities and outreach programs. In the government sector these health facilities include General Rural Dispensaries (GRDs), Rural Dispensaries (RDs), Mother & Child Health (MCH) Centers, Basic Health Units (BHUs), Rural Health Centers (RHCs), Tehsil Headquarters (THQ)/ District Headquarters (DHQ) and Teaching Hospitals. And in the private sector these are mostly the hospitals and clinics run by individuals or organizations.
There are many other allied services that complement the provision of health care, for example, pharmacies, pharmaceutical companies, laboratories and the industries that manufacture medicines and instruments that are used in the provision of health services.
In order to understand the role and relationship of the obvious actors engaged in the provision of health services mentioned above one needs to ask questions like:
· What networks all these ‘health facilities’ and enables them to provide the services that they provide?
· What determines how the service providers will be trained?
· Who governs the provision of health services and determines the scope of services that will be provided at each facility level?
· How are the services paid for if the community does not pay when receiving the services or if they pay where does the money go and what happens to it?
There are various people that can be broadly grouped together based on the functions that they have:
a. The people who NEED health services due to disease and ill-health. These people are the users or the clients of the health services. In some cases they pay directly for receiving health services and in some cases services are provided to them free of any direct payment.
b. The people who PROVIDE SERVICES, such as dispensers, LHVs, doctors, LHWs, nurses etc. etc.
c. The people who ORGANIZE the provision of health services according to the national, provincial and district priorities and policies. They also manage the health care providers and ensure that financing is available. They plan and manage the entire service provision and production of professionals who are needed to provide the services.
Thus based on the above broad functions-based grouping it is visible that the coordinated functioning of these groups will enable an effective delivery of health services. This in its simplest form is the description of a ‘health care system’. The simple diagram below will help us understand the health care system in its simplest form.











Figure 1: A simplified view of the Health care System

In a government health system, the Organization/Institution in the Health Department, the Service Providers are the dispensers, LHVs, doctors, LHWs, nurses etc. and the Community are the people who need and use services.

An important point to understand and note is that even in the government health sector the provision of services is not really ‘free’. The people who provide services (dispensers, LHVs, doctors, LHWs, nurses etc.) are paid to provide services and the medicines and equipment is also provided and paid for by someone. The money for the salaries, medicines and equipment and many other expenses comes from the federal, provincial and district governments’ finance sectors. The finance ministry or departments in turn obtain finances that are collected from people in the shape of various taxes which fuel the government machinery. Therefore to assume that the poor people who come to obtain health services at government health facilities receive ‘free’ services is a wrong notion and must be rectified. The people who receive services may not have to pay at the time of obtaining services but they surely pay in the form of various taxes that are levied upon them. Therefore it is their right to receive quality health services and it is our responsibility to provide these services in a way that our users’ dignity is maintained.
The structure of health care delivery
The health care services are provided to address various intensities of disease and ill-health. For example, a simple case of cough and fever needs a different level of health care as compared to the level of health care needed for a case of severe pneumonia. While the prevention of disease a different level and process of health care.

Based on the type and level of response being provided the health care delivery can be categorized in the following levels:
a. Primary
b. Secondary
c. Tertiary

Each of the above level of health care has its own set of responsibilities and roles which are critical to the overall design of the health care system. Below is a brief description of the roles and responsibilities of the three levels of health care delivery:

a. Primary level
This level pertains to the prevention of disease and ill-health in the community. The role is therefore largely of health promotion and community engagement for improving health behaviors. Some extremely important health services are positioned at this level including Health Promotion and Education, Vaccination, Antenatal and Postnatal Care, Nutrition Education, Personal and Community Hygiene etc.

It is therefore evident that this is the largest segment of health care delivery system as it addresses the biggest proportion of health issues in our country, of which most are preventable diseases. It heavily relies on health communication, provision of basic curative services including emergency obstetric care.

The health facilities and services at this level are:
· Outreach health services – vertical/national health programs
o Expanded Program for Immunization (EPI)
o Malaria and Control of Communicable Diseases Program
o National Program for Family Planning and Primary Health Care
o Maternal, Neonatal and Child Health Program
o AIDS Control Program
· Facility based basic curative health care at
o Rural Dispensaries (RDs) and General Rural Dispensaries (GRDs)
o Mother & Child Health (MCH) Centers
o Basic Health Units (BHUs)
o Rural Health Centers (RHCs)

b. Secondary level
This level pertains to management of common diseases including routine medical, surgical and obstetric care. Treatment of diseases which does not require sophisticated care is positioned at this level. Traditionally preventive health services especially vaccination and MCH services are also linked with the secondary level health care, although this level is largely facility-based. Services are typically organized into discipline-based units such as Medical, Surgical, Gynecology & Obstetrics, Ophthalmology and Ear Nose Throat (ENT).

It is therefore evident that this segment of health care delivery system deals with disease management which is not possible at the primary level and needs more advanced medical care. Therefore a significant proportion of services is comprised of inpatient care.

The health facilities and services at this level are:
· Tehsil Headquarters Hospital
· District Headquarters Hospital
· Facility based preventive health care programs
o Expanded Program for Immunization (EPI)
o National Program for Family Planning and Primary Health Care

c. Tertiary level
This level pertains to advanced treatment and rehabilitation of advanced or complicated diseases. Ideally the tertiary level should only deal with cases that are referred to it by the secondary or primary levels. Services are typically organized into comprehensively organized discipline-based units such as Medical, Surgical, Gynecology & Obstetrics, Ophthalmology and Ear Nose Throat (ENT). Advanced and sub-specialty disciplines are also included in tertiary level health care, for example Oncology, Pulmonology, Pediatric Surgery, Cardiac Care etc. Comprehensive laboratory facilities complement tertiary health care.

It is therefore evident that this segment of health care delivery system deals with a very small proportion of diseases but those which cannot be managed at primary or secondary levels. This level of health care has intensive inpatient care. Traditionally tertiary level health care is associated with teaching of medical and nursing students including internship of fresh graduates. Advanced medical research activities are most common at this level.
The health facilities and services at this level are:
· Tertiary Hospitals
· Teaching Hospitals
· Specialty Hospitals
· Research Institutes
The Role of Dispenser in the Health System

The Role of a Dispenser (Approved Nov 2007)
The role of the dispenser presented below has been defined in view of the contemporary needs and context in which the dispenser has to work. The role represents the broad areas of agreement on which the dispensers training, examination and performance need to be based in order to address the dissonance between their training, examination and utilization in the health care system.
Work Activities
· Dispensing medicines & maintaining stocks
· Administration of injectable medicines to health care clients
· Nursing care in secondary and tertiary hospitals and RHCs
· Working as first line handlers of emergencies and victims of trauma
· Working as dressers in hospitals, RHCs and BHUs
· Imparting health education to health care clients and their immediate relatives
· Linen & instrument sterilization
· Working as OT Assistants
· Working as storekeepers at health facilities for both specialized and general stores
· Maintaining health information system records (HMIS/DHIS)
· Managing front office & mob control
· To assist MOs (non-specific) & cover BHU in case of the absence of MO
· Running OPD & writing prescriptions in the absence of MOs, especially at BHUs and RHCs
· Parchi fee collection & maintaining financial records
· Working as clerks in office assisting administration units of hospitals, RHCs and BHUs
· Working as caretakers of buildings at RHCs and BHUs
· Teaching dispenser students
Behavioral Requirements
· Communication skills
· Decision making skills
· Team-working skills
· Client care skills
Technical Requirements
· Skills to operate & maintain medical equipment such as BP apparatus, thermometer, dressing trolley, surgical instruments, autoclave etc.
· Recordkeeping (stock ledgers etc) skills
· Skills to maintain MIS records
· Basic knowledge of pharmacology & pharmacy
Qualifications Required
· Matric or FSc (both with science subjects) - to be enrolled in Dispensers Training Program
· PMF dispenser’s certification.
Job Description of Dispensers from one of the approved PC 1 forms
· Dispenser/Dresser
· Job Title: Dispenser/Dresser
· BPS: 6 (33% selection grade)
· Relationship:
o Reports to Medical Officer/Attendant in charge of the health facility for the duties assigned to him. He supervises the junior staff posted with him.
· Qualifications:
o Dispenser’s Diploma from the Punjab Medical facility
· Recruitment:
o Direct by appointing authority/board constituted by the government for the purpose
Duties as Dresser:
· He performs duty both in the outpatient and inpatient departments and is responsible for the efficient dressing of the patients.
· He indents/linen/dressing and maintains the ledgers and stocks accordingly.
· He dispatches the dirty linen for washing and receives back the washed linen.
· He prepares and keeps the dressing trolley in order and ready for emergency.
· He prepares the dressing drums for autoclaving by himself or at the central autoclave unit.
· He accompanies the medical officer in the outpatient and inpatient rounds and assists him examining the patients.
· He carries out the dressing of the patients with simple injuries and assists in or carries out dressing of the serious injuries under the guidance of medical attendant/officer.
· Duties as Storekeeper Medicine Store/General Store:
· He is responsible for the efficient running of the medicine store including dispensing of the prescribed/indented drugs.
· He prepares mixtures, lotions, suspensions, ointments, powders, liniments etc. in accordance with the prescriptions using standard pharmacological procedures.
· He dispenses prescribed drugs and medicines to the patients according to the prescription and furnishes sufficient information to the patients on the use of the dispensed drugs.
· He maintains the medicine store properly and shelves the drugs as required and in a manner that their maximum bio-availability is maintained.
· He is responsible for the safe custody of medicines and is responsible to keep the medicine stock up to date and the current stock position depicted on appropriately displayed bin cards.
· He shall keep the stock register updated and is responsible to inform, well in time, the medical attendant/officer in charge of medical store or health unit about the stock position of drugs in order to arrange replenishments.
· He shall check all stocked drugs every month and bring to the notice of the medical officer/attendant in charge the expired/destroyed drugs and those near expiry. He shall assist in charge in the disposal/destruction/struck of the stock of such items by the competent authority.
· He shall assist the medical officer/attendant in charge in preparing the annual or contingent/emergency indents for the supply of drugs, equipment, linen etc.
· If the dispenser officiating store keeper for medicine store is entrusted the general store (non-medical items), he shall perform this duty as prescribed for medical store and as entrusted above.
· He is responsible to receive/collect the deliveries of stock items, medical or general, form the main store, MSD or DHO/DDHO office etc as the case may be.
General Duties:
· He performs the duties in accordance with the duty roster and follows the routine as required of him.
· He shall not leave the premises of his work station unless relieved/replaced by a bonafide incumbent.
· He shall carry out emergency duty for the prescribed duty hours and shall not, in any case, leave the premises of his work station unless relieved/replaced by a bonafide incumbent. He shall, however, remain ‘on call’ and must keep his movements informed to the responsible person at the health unit where he is working.
· He shall, in the absence of a senior the medical attendant, administer treatment to the patients with minor diseases. However, in case of serious illness he shall, after giving first aid, refer to the next referral health unit.
· He provides nursing care to the admitted patients which includes, inter alia, passing the Ryles tube, flatus tube, catheterization, bedding and clothing of patients. He is responsible for measures for prevention of bed sores, recording of vital signs, temperature, blood pressure, pulse, respiratory rate etc. administration of medicine, preparation of patients for diagnostic procedures e.g. X-ray etc. and carrying out instructions for preoperative preparation and post operative care.
· He regularly maintains the OPD register, abstract register, daily register and if required, the registers pertaining to cash, admission, diary and dispatch, infectious disease surveillance, acquaintance roll etc.
· He shall, at the direction of the in charge medical officer/attendant, work as official in charge of the state building lawns and premises and take measures for their maintenance and appropriate upkeep and report to his superiors, if required.

Brainstorm
Ask students:
What is communication?
How can we express ourselves properly?
What is health communication?

Basic Communication Skills
What is Communication?
Communication is a process by which we ‘give’ and ‘pass on’ meaning in order to create shared understanding of what we are trying to say or express. In this process we are transferring (or trying to transfer) information from a us, i.e. sender, to someone else, i.e. receiver, by using a medium, usually language, in which the communicated information is understood by both the sender and the receiver.
Communication skills are the skills needed to use language (spoken, written, signed, or otherwise communicated) to interact with others. This process requires a wide range of skills in intrapersonal and interpersonal processing, listening, observing, speaking, questioning, analyzing, and evaluating. Use of these processes is developmental and transfers to all areas of life such as home, school, community, work, and beyond. It is through communication that collaboration and cooperation occur.
It is a process that allows us to exchange information by several methods. However, communication is not passive. It is an active process of sharing, interpreting and receiving information. It is affected by cultural, social and personal elements. This process depends on a series of experiences:
· Hearing
· Listening
o (the difference between hearing and listening is huge; hearing is an involuntary process where we do not have a choice unless we plug our ears whereas listening is a voluntary and active process where we make an effort to pay attention to what is being said.)
· Seeing
· Smelling
· Tasting
· Feeling
4.10. Forms of Communication
Generally, communication takes the following 4 forms:
· Listening
· Speaking
· Writing
· Reading
We convey our thoughts or feeling to others through the process of communication. How others receive it depends on a set of events and experiences that others have been exposed to. How we say what we say plays an extremely important role in communication.
When we communicate we are saying words that make one part (verbal) of communication process. But we are also using our body language and vocals expressions while communicating. These make the other two parts of the communication process. Thus communication has the following three components:
· Verbal - the words we choose
· Para-verbal - how we say the words
· Nonverbal - our body language
The collective effect that our communication has on others is analyzed below:
· Words, less than 10%
o Words, though important, are only labels and listeners put their own interpretation on speakers words
· Para-verbal or vocal expressions or use of voice such as tone, pitch and modulation, less than 40%
o The way in which something is said - the accent, tone, clarity and voice modulation is important to the listener.
· Body Language, more than 50%
o What a speaker looks like while delivering a message hugely affects the listener’s understanding.
Verbal communication, though important, is considered to be less important when compared with nonverbal and para-verbal parts of communication. The para-verbal and non-verbal communication is a blend of our body language that includes posture, gestures, facial expression, repetitive movements, and general attitude. It also includes our tone and variation of our voice. Thus, health care providers need to be aware of their own communication styles as well as the unspoken messages being communicated.
Active and effective listening is a powerful communication technique. It builds trust, increases understanding, reduces tension, facilitates decision making, reduces conflict, encourages participation, and creates openness. Moreover, it makes people feel valued - we all like to be listened to.
Health Communication:
Health communication is the study and use of communication to inform and influence individual and community decisions that improve health. It links the areas of communication and health and is increasingly recognized as a necessary element of efforts to improve personal and public health. Health communication can contribute to all aspects of disease prevention and health promotion and is relevant in a number of contexts, including:
· health professional-patient relations
· individual’s exposure to, search for, and use of health information
· individuals’ adherence to clinical recommendations and regimens
· construction of public health messages and campaigns
· dissemination of individual and population health risk information, that is, risk communication
· images of health in the mass media and the culture at large
Effective health communication can help raise awareness of health risks and solutions provide the motivation and skills needed to reduce these risks, help them find support from other people in similar situations, and affect or reinforce attitudes. Health communication also can increase demand for appropriate health services and decrease demand for inappropriate health services. It can make available information to assist in making complex choices, such as selecting health plans, care providers, and treatments. For the community, health communication can be used to influence the public agenda, advocate for policies and programs, promote positive changes in the socioeconomic and physical environments, improve the delivery of public health and health care services, and encourage social norms that benefit health and quality of life
Attributes of Effective Health Communication:
· Accuracy: The content is valid and without errors of fact, interpretation or judgment.
· Availability: The content (whether targeted messages or other information) is delivered or placed where the audience can access it. Placement varies according to audience, message complexity, and purpose, ranging from interpersonal and social networks to billboards and mass transit signs to prime-time TV or radio, to public kiosks (print or electronic), to the internet.
· Balance: Where appropriate, the content presents the benefits and risks of potential actions or recognizes different and valid perspectives on the issue.
· Consistency: The content remains internally consistent over time and also is consistent with information from other sources (the latter is a problem when other widely available content is not accurate or reliable).
· Cultural Competence: The design, implementation, and evaluation process that accounts for special issues for select population groups (for example, ethnic, racial and linguistic) and also educational levels and disability.
· Evidence base: Relevant scientific evidence that has undergone comprehensive review and rigorous analysis to formulate practice guidelines, performance measures, review criteria, and technology assessment for tele-health applications.
· Reach: The content gets to or is available to the largest possible number of people in the target population
· Reliability: The source of the content is credible, and the content itself is kept up to date.
· Repetition: The delivery of or access to the content is continued or repeated over time, both to reinforce the impact with a given audience and to reach new generations.
· Timeliness: The content is provided or available when the audience is most receptive to, or in need of, the specific information.
· Understandability: The reading or language level and format (including multimedia) are appropriate for the specific audience.
Rules of Effective Communication:
Always remember the abbreviation of “W E L L”
· W : Welcome your client or patient
· Always receive clients warmly, respect them and give them a friendly treatment within the cultural norms of the community that you are working in
· Offer your clients a seat (chair)
· Ask his or her name, this is essential for identity and records
· Show empathy, sympathy and compassion while communicating with your clients or patients. You can use sentences such as e.g. “I can understand how you are feeling” or “I know how you are feeling”.
· E : Encourage your clients or patients to talk
· Ask routine questions such as “Would you like to tell me your problems?”, “What are you worried about the most ?”
· Show empathy and your interest by your non-verbal behavior such as nodding your head and making affirmative gestures while talking. Use verbal ‘neutral’ encouragers such as …‘ go on’; ‘uh-uh’…’Ok’…‘yes’…or ‘I see’ - This ensures that you are actively participating in the conversation. It gives a clear message that you understand what your client is saying and you care for your client or patient. You can encourage the client by saying, “Please tell me more about your sickness”
· Ensure confidentiality of client’s medical and personal history. This builds trust and credibility between health care providers and clients.
· L : Look at your patient
· Ensure sincere, relaxed and friendly expressions on your face. DO NOT LOOK BLANK. This discourages clients from talking.
· Keep a relaxed eye contact with clients and patients while talking to them. However, keep yourself within the boundaries of the cultural norms of the area or the community that you are working in. DO NOT STARE.
· Notice and observe feelings and emotions of your clients and patients (this will help you in examining his or her health condition as well)
· L : Listen to your patient
This is the most important part of communication!
· Listen carefully and sincerely to whatever your patient or client is saying WITHOUT interfering or interrupting. If you interrupt, clients or patients get discouraged. However, if a client or patient is going into unnecessary details or appears to be a time waster, politely guide your conversation to relevant points.
· Pay full attention to what your client or patient is saying through your gestures and body language. Words seldom capture all there is to say. Nonverbal cues say a lot. These things can reinforce messages and create sincerity.
· Note nonverbal cues or indications coming out of your patient or client and explore them further with your questions.
· Try to look at your patients’ or clients’ point of view. Listen actively and with empathy; as if you see the situation from their eyes or you place yourself in their situation (put yourself in their shoes!). You will understand and be able to assist them better. This will also build a relationship of trust between you and your clients.
· Remember each individual perceives things differently. Therefore, it is important to consider the other person’s point of view so that you could to have an accurate perception of your clients’ situation.

Sub-unit 1.1
Gender Issues in Health
Learning Objectives
After completing unit 8 dispenser students will be able to:
a. make a differentiation between gender and sex
b. describe the importance of gender in health

Brainstorm
Ask students:
What is gender?
Why is gender important in health care delivery?

1. Gender
Gender refers to the socially constructed roles, behavior, activities and attributes that a particular society considers appropriate for men and women.
The distinct roles and behavior may give rise to gender inequalities, i.e. differences between men and women that systematically favor one group. In turn, such inequalities can lead to inequities between men and women in both health status and access to health care.
The socio-cultural definition given to a man or a woman in a particular society is called “GENDER”. It is different from “SEX” which differentiates men and women in biological terms.

Sex does not determine what role a man or woman will be playing in his or her life. The social relationships are defined by prevailing social values, believes and behaviors. However “gender roles” are described on the basis of one’s “sex”.
What is “Gender” and what is “Sex”?
Many people confuse the terms “sex” and “gender” or
aren’t sure what exactly they mean.
· Sex: This refers to biological differences
between women and men and is genetically determined.


· Gender: This refers to the socially determined
differences between women and men, such as roles, attitudes, behaviour and values.
Comparison of sex and gender
SEX
GENDER
Universal
Differs
Unchanging
Dynamic
Given
Learnt
Biological determined
Social construct

Activity
Please tick the right statement in relevant column

Statement
Gender
Sex
1.
Men can’t cook


2.
Women earn less money than men do


3.
Women have larger breasts than men


4.
Girls drop out of school more than boys do


5.
Women cannot own land


6.
A man is the head of the household


7.
Men don’t cry


8.
Girls dress in pink, boys dress in blue


9.
Women menstruate, men don’t


10.
It is not the job of the father to change nappies


11.
There are more male leaders than female leaders


12.
Women are natural child care providers


13.
There are more male technicians than female technicians


14.
Girls like dolls and boys like guns and cars


15.
A man can drive better than a woman


16.
A man cannot get pregnant


17.
The man is the bread earner


18.
Men make good doctors, women make good nurses




Gender-based Fact Sheet for Pakistan
It is recognized that in Pakistan, as in many other member states many women in particular do not enjoy many of the rights laid down in the Universal Declaration of Human Rights. Despite the best efforts of the Government, many NGOs, CBOs and other women’s organizations, there remains in Pakistan as in many other member states of the Universal Nations, a significant disparity between these statements of principle and day to day reality.
Gender disparity can be seen, for example, through the lens of the gender related development index (GDI) and the gender empowerment measurement (GEM) both introduced in 2007-08 UNDP Human Development Report. Pakistan’s GDI ranking is 125 out of 157 countries whilst its GEM ranking is 82 out of 93 countries.

Below are some human social indicators concerning to women in Pakistan:


Women’s representation
Literacy rates
35.4%
Gross primary enrolment
75%
Combined enrolment ratio
34%
Maternal mortality
340 per 100,000 live births of female
(Global Health Foundation)
Mortality rate (1-4 years)
12% higher than males
(ADB Women Health Project)
Labor force participation
16%
Earned income share
20%
Women in govt. ministerial level
5.6%
Seats in parliaments (Senate)
17.0%
Seat in parliament (N. Assembly)
21.3%
Legislators, senior officials and managerial jobs
2%
Female professionals and technical workers
26%

Women’s Health Situation in Pakistan
In Pakistan, as in many other member states of the United Nations, many women in particular do not enjoy the rights laid down in the Universal Declaration of Human Rights.

Health
[1]Life Expectancy at birth (years) 2002
Women
63.4
Men
63.7
1Probability at birth of surviving to age 65 (2000-05)
Women
61.9
Men
60.0
1Births attended by skilled health personnel (%) 1995-2002
20.0
Anemic women of child bearing age
58%
[2]Women (45 years of age and above) of low income in rural areas suffering from poor health
Almost 45%
3Individuals (45 years of age and above) of low income in rural areas suffering from poor to fair health
Women
>80%
Men
60%
According Pakistan Demographic Health Survey 2006-07 report

Under Five Mortality Rate
94/1000
Newborn Mortality Rate
54/1000
Infant Mortality Rate
78/1000
Maternal Mortality Ratio
227/100000
% of deliveries attended by skilled birth attendants at home/ Health Facilities
38%
Contraceptive Prevalence Rate
36%
The above stated factual situation of women in Pakistan create great demand for improvement of health and other indicators concerning women to enable them enjoy equal health status as that of men.
Division of role vs division of resources
Gender roles
· Productive role
· Reproductive role
· Community role

· In every society men play “two roles” while women play “triple role”
· Gender roles of men and women determine who needs what kind of resources, benefits, skills, knowledge and opportunities
· Development demands an active and shared role of men and women in productive, reproductive and community sphere

Reproductive Activities (“INSIDE”): Recognized as ‘Natural’
Productive Activities (“OUTSIDE”): Recognized as ‘Work’
Roles:
Child bearing/rearing responsibilities and tasks – required to guarantee maintenance and reproduction of labor force; includes care and maintenance of the current and future work force (infants/school kids).
Roles:
Work undertaken for pay in cash or kind – includes market production and subsistence / home production.


Community Managing Activities (“INSIDE/OUTSIDE”): Recognized as ‘Natural
Community Activities
(“Outside”): Recognized as ‘Work’
Roles:
Activities in the public sphere of the community, such as participating in a farmers or a women’s group, attending religious meetings, organizing social events and services, community improvement tasks, maintenance of scarce resources of collective consumption, i.e. water, fuel, attending to the elderly sick and disabled. It involves voluntary time and is important for community organization and development.
Roles:
Activities at community level where decisions are made with regard to access to and control over human and material resources. Would involve participation within the framework of national or local politics – generally paid work directly or indirectly (financially rewarding) through STATUS or POWER.

Activity
Please tick which of the following resource will go to a girl and a boy in the relevant column:

Available resource
Girl
Boy
Gun


Doll


Cricket Ball


Ring


Neck Tie


Truck/van (toys)


Hair comb


Racket


Bangles


Knife


Color pencils


Painting brush


Beads


Scissor


Arrow


Computer


Telephone


Ring bell


House (toy)


Fire engine


Stove


Gender stereotyping
Gender issues arise when gender stereotyping prevents men or women from enjoying their full potential and human rights. Gender issues emerge when gender roles result in:
Invisibility of either gender
Women and men’s multiple roles have to be recognized. If not, one of the gender will tend to become invisible or undervalued, e.g. the roles that women play in the reproductive domain; or women’s contribution to the productive domain in terms of farming, management of livestock, mushroom farming, sericulture, etc. is not factored into interventions. Similarly, men’s absence from the reproductive domain means that they lose out on care and close bonding; women’s absence from the political domain (before devolution) did not allow women’s representation in decision making.


Unequal burdens of work for either gender
Men and women often have different needs and priorities due to their different status and roles in society. Therefore development interventions affect men and women differently. Men and women are interested in those interventions that make their lives easier to manage. Unless the needs and priorities of both women and men are addressed, humane, just and sustainable development is not possible.





Unequal access to, and control over, resources
Gender issues also arise when one gender has a greater access to, or control over, resources, including education, training, land, credit, health, labor, income, technology, information, political power, transport, etc. Only if the relationship between men and women is equitable can men and women fully participate in and benefit from development. And development results must consciously define the benefits of any intervention for both men and women.


· Gender Equity is the process of being fair and just to both men and women in view of the respective needs of both the genders
· Gender Equality means that women and men enjoy the same status within a society
· Position: Equal rights, position, powers and authorities
· Condition: Serve more to the one who have less rights, powers, authorities and position by giving the resources, benefits, opportunities, skills and knowledge,
Equity is needed to improve the condition as well as position of all those who are left out in the development process including women.

And the behavior or action of any person in favor of the same is called “equitable treatment” and that is the major indicator of gender sensitivity and leads to empower all marginalized including women and enjoy the same status in the society.

Gender and Health
For understanding the relationship of gender with health we should first understand the determinants of health. According to Health Promotion Framework, Ottawa Charter following are the determinants of health (Also please see Unit 4):
· Economic resources
· Governing policies and laws
· Biological factors
· Environmental factors
· Living conditions
· Social believes, culture and ethnicity
· Gender

In each of the determinants of health, the social definition ascribed to a man or a woman in a particular society, i.e gender, plays an important role:
Determinants of health
Gender plays a vital role in
Economic resources
Defining women’s and men’s access to economic resources
Governing policies and laws
Defining women’s and men’s access, representation and involvement in policies and laws formulation
Biological factors
Deciding reproductive rights and control over body and health by a man or a woman
Environmental factors

Defining relationships of men and women in maintaining bio diversity, de-forestation, energy conservation, water and food preservation etc
Living conditions
Defining men’s and women’s role in improving the living conditions within families and in the surrounding
Social believes, culture and ethnicity

Overcoming gender myths, stereotypes and prejudices prevailing in a particular society that tend to marginalize the most vulnerable including women


The combination of gender with poverty (two important determinants of health) put a combined effect on different disease patterns among men and women.

UNDP (1995), report by Dr Mahboob-ul-Haq made a research for en-cashing socially reproductive role of women and showed that

2/3rd (67%) of the total work in the world women do
1/10th (10%) of the total world’s profit women get
1/100th (1%) of the total world’s property belong to women




Examples:
· A woman cannot receive needed health services because norms in her community prevent her from traveling alone to a clinic.
· A teenage boy dies when he jumps into the canal because of trying to live up to peers’ expectations that young men should be “bold” risk-takers.
· A country's lung cancer mortality rate for men far outstrips the corresponding rate for women because smoking is considered acceptable for a man, while it is frowned upon as unfeminine in women.
· A woman cannot receive needed health services because norms in her community prevent her from traveling alone to a clinic.

Conclusion:
Gender norms and values are not fixed. They evolve over time, vary substantially from place to place, and are subject to change.

Thus, the poor health consequences resulting from gender differences and gender inequalities are not fixed, either. They can be changed.

Why aim for gender equality in health sector
· Women are underrepresented in the middle and top management of the health department at the national, provincial and district level. Currently, for example, there is no woman Executive District Officer for Health (EDO-H) or District Officer Health (DO-H) in the entire province of the Punjab (with 34 districts)
· On the basis of the limited understanding of gender issues, health planners and managers are of the view that as most of their programs target women, they and their departments are gender-sensitive
· Top down approach of the health planners and managers and limited understanding about gender
· Lack of technical skills such as gender analysis and appraisals
· Lack of evidence based planning and absence of gender disaggregated data
· Lack of women technicians
· Low status of women technicians, LHVs and Dais as compared to the men
· Staffing of LHWs in remote areas – an issue
· Lack of suitable accommodation for women belonging to other area
· Shortage of women MOs
· Lack of gender division of resources and distribution of roles between men and women
· Lack of pro poor gender sensitive planning and budgeting
· Gender blind institutional policies and procedures
· Lack of women in the planning and decision making forums
National and international commitments to gender equality:
· National Health Policy 2001 puts ample emphasis on promoting gender equity in health systems
· Millennium Development Goals emphasize proactive attention to women issues in health particularly maternal and infant deaths
· Alma Ata declaration endorsed “health for all”
· Health Sector Reform Program planned in 2002 endorsed gender equality in the health sector
· Convention on Elimination of All sort of Discriminations Against Women (CEDAW) ratified in 1995 shows state commitment to ensure women’s economic empowerment, reproductive health needs and basic right to education.


Gender Analysis
Gender analysis is the careful examination of a particular area of health to determine if, and in what ways, gender norms, behaviors, and inequality are contributing to poor health, disability, mortality, or lack of well-being
· Gender analysis provides a deeper understanding of the situation for and between men and women, their constraints, needs, priorities, and interests.
· Gender analytical information (results of gender analysis) is essential in designing good policies – because it tells us why the differences exist – the causes.
· Gender analysis is an important part of policy analysis that identifies how public policies (or programs/projects) affect men and women differently.
· Conducting gender analysis requires well-developed social and gender analytical skills and is usually carried out by appropriately trained and experienced social researchers or gender experts.

Gender analysis- a way to Gender mainstreaming

All health professionals must have knowledge and awareness of the ways gender affects health, so that they may address gender issues wherever appropriate and thus make their work more effective.

The process of creating this knowledge and awareness of - and responsibility for - gender among all health professionals is called "gender mainstreaming”.

Setting up a system of doing regular period gender analysis of the DHIS data will be the first step towards gender mainstreaming in health system


Case Study 1

Manzoor Hussain Dispenser is sitting in the OPD of RHC Chotti Zerin. A 25 years FTP woman comes to him with a 1 year old baby girl. Baby girl is suffering from Diarrhea. Manzoor Hussain enters the data on the OPD slip and refers the patient to the SMO’s room. On her return, she asks him from where to get the medicines, he directs her while doing entry on the CRP register.


Q 1-What is your opinion about the role of dispenser?
Q 2-What are the particular actions/steps which he could have performed in this particular case?

Case Study # 2


Dispenser Sadiq Jalal is sitting in the OPD of DHQ Hospital. There are 7 patients comprising of 6 males and 1 female. Female is carrying a baby and who is crying and coughing badly. She is requesting the dispenser to give her OPD slip out of her turn as she has a cranky baby on her hands and she has traveled from far but he pointedly asks her to wait for her turn.


Q-1- How do you think that dispenser should have ideally dealt with the woman?
Q-2- What should be the system to handle male/female clients?
Q-3- In this particular situation how could the dispenser have performed a role as an active health promoter?