Basic Features Of Health Health And Social Care Essay

INTRODUCTION

The access to health care is a basic human right. (Ali, 2000). This right is duly accepted in the Article 25 (1) of the Universal Declaration of Human Rights. (UNO, 1948; Youth for Human Rights International, 2010). The concept of primary health care has been defined as: "Primary health care is essential health based on practical, scientifically sound and socially acceptable methods and technology, made universally, accessible to individuals and families in the community through their full participation and at a cost the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self determination." (WHO, 1978).

The primary health care approach needs effort by the community, NGOs, and Government at grass-roots level. In Pakistan, especially in Karachi, the health situation is not very satisfactory. The health system faces many problems. During the last two decades, a number of studies were conducted on health situation. The role of NGOs in the promotion of health was considered crucial. (FPAP, 99; Karim,98; NGORC,96; SPO,94; TVO,1994; UNDP, 1997).

The study in hand entitled: "Promotion of Primary Health Care in Pakistan: A Case Study of the Role of Non-Governmental Organizations in Promoting Primary Health Care in Karachi" entails focus on issues like: basic features of health, fundamentals of primary health care, primary health care in Pakistan, the role and critique of NGOs involved in primary health care, and the highlights of primary health care programs of some NGOs in Karachi.

The chapter covers: back ground of the study, significance of the study, primary health care in Pakistan, the role of NGOs in primary health care, primary health care programs of some NGOs in Karachi, objective and hypothesis of the study, methodology of research, layout of the study, key terms in the study, and research sources.

1.1. BACKGROUND OF THE STUDY

The role of NGOs in the promotion of primary health care can be ascertained by the analysis of two aspects. These are the explication of components and factors related to health, and then indication of strategies to implement primary health care approach.

This section presents: basic features of health, and fundamentals of primary health care.

Basic Features of Health

Definition of Health

Health has been seen and defined from different standpoints. The biomedical approach described health as a deviation from the biological norm, and termed health as an absence of disease. This approach ignores the presence of psychological entities, and lays stress on medical and technical treatment. (WHO, 1982; Henslin, 2005). The holistic approach laid emphasis on environmental, socio-economic, psychological, and physiological factors in its definition of health. (Leighninger and Popple, 2000; Benton, 2000). The general system approach saw humans in terms of a hierarchy of interrelated and natural system (Leighninger and Popple, 2000).

J.M. Henslin in his discussion on "Medicine and Health" (2005: 542-575) described health as a "human condition measured by four components: physical, mental, social and spiritual."

Henslin explained theoretical approaches to the issues of health. He considered AIDS as a threat to health, and mentioned some issues in health care. He examined the health system in China, Russia, and Sweden. His search for alternatives in the health care policies is related directly to the research in hand.

W. Benton (2000:74) saw health as a state of complete physical, social, mental, and economic well-being and not merely the absence of disease and infirmity. He noted: "Health is a right difpofication of all the body and of all its parts; confiding in a due temperature, a right confirmation. Just connection and ready and free exercise of the several vital functions." (AKU, 1987).

The definitions just mentioned suggest that the issues of health care need to be seen in their entirety. Health and illness are seen differently in societies. The industrialized countries have more developed public health systems. The access to health facilities, differs in the developed and the developing countries. The availability of the clean water is taken for granted in the industrialized countries. In contrast, more than 1 billion of the world’s people are without approach to clean water supply. (Kamal, 2010; WB, 93; WHO, 2003).

The basic components of health, and the sociological factors of health are seen and interpreted differently in societies.

The Components of Health

Three elements of health were identified by experts back in 1941. These are: physical, mental, and social. (WHO,1946). In this identification the spiritual aspect was not included. It may be noted that religion is closely connected with spiritual matters. (Henslin, 2005:488-517; ThIo,1996:385-407). The functionalists’ perspective emphasizes that religion provides practical directions on how to live our everyday lives. (Henslin, 2005: 489-492; Theo, 1996:389-391). The adherents to the teachings of Judaism's, Christianity, and Islam are less likely to abuse alcohol and illegal drugs than other people. (Henslin, 2005). Thus, spiritual aspect becomes an essential component of health.

The four components of health: physical, mental, social, and spiritual need to be promoted through individual and collective efforts of the community. The study of disease and disability patterns in the population calls for serious research. (Henslin, 2005; Twaddle; 38-48). It is only through the process of research that the primary health care issue can be identified. Health policy is dependent on the correct assessment of issues related to the four components of health (Henslin, 2005:524; WHO, 2004).

The Sociological Factors of Heath

Health is not confined only to consideration of biological matters. Health is intimately related to society. (Henslin, 2005; Robbins, 2007; Twaddle, 1987; Theo, 1996). Four sociological factors have visible implications for health. These are: structure of society, lifestyle of citizen, public health system, and the environment.

Structure of Society: The level of inequality and gap between rich and poor in the society impacts on the standard of health. (Arif, 2002; Borges, 1995; Irbil, 2001; Iqtidar, 2003; Henslin,2005:523;UNDP,2003;WB,1993; Zaidi,1995).The access to medical facilities influences the standard of health. Health inequality manifests itself in many ways. For instance, higher infant mortality rates and lower life expectancy is found in poor people. (Bhutta, 2011, Bryant, 97, PMA, 2011). The pattern of disease differs in the well-to-do and the poor. Obesity is generally seen among the more affluent. (Gulf News, 2006; Khanani, 2011; Sheikh, 2008;WHO, 2004).

Lifestyle of Citizens: The lifestyles associated with poor health include: poor diet, lack of exercise, excessive use of alcohol and drugs, smoking cigarettes and social isolation. (Bhutta, 2011,WHO, 2011). The lifestyle factors are difficult to control through Legislation alone. The legal ban on smoking cigarettes needs community support for its implementation. (WB, 1993). The changes in lifestyles and its effects on health, is a subject for serious research.

Public Health System: The state of health is closely related to health politics of nations. (WB,1993; Zaidi, 1995). Public health system strives to improve health conditions of the citizens. The system is composed of government-run health programs. The focus of these pogrammes is to ensure clean drinking water, sewage and sanitation services, and measures against infectious diseases. (Iliyas, 2003; Munir, 2002; Zaidi,1995). Support for public health programs often sought from donors and NGOs. Health care system, comprised of clinics, Hospitals and other medical facilities reflects the strength of public health system in a country.

The Environment: Major health risks are posed by the environment constructed by humans. The incidents of Chernoby1 nuclear reactor in Russia, and leak from a pesticides factory in Bhopal (India) are lasting reminders of environmental risk to health. (Broughton, 2005:4-6 ; UNSCEAR, 2011). The environmental profile of Pakistan (GOP, 1997) provides directions to deal with the issues related to the environment. The thermal power plants are reported to be major contributors to atmospheric pollution and hazard to health. Pollution in Karachi and other cities of the country pose serious risk to health. (Younis, 2004).

The basic features of health, discussed above, help to focus on the fundamentals of primary health Care.

(2) Fundamentals of primary Health care

The idea of primary health care was suggested in a book jointly authored by K. Newell and E. Amundsen in 1973. The forward-looking concept of primary health care was formally adopted by the WHO in the Alma Ata Conference in 1978. (Helander, 2000). The Alma Ata declaration was aimed to give shape, and realize the goal of World Health Assembly call: "Health for all by 2000 AD."

In the Alma Ata Declaration (WHO , 1978), primary health care has been defined as "essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally, accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination."

In the above definition, PHC has been considered an approach to health which is clearly beyond the traditional health care system. The definition helps to discern the fundamentals of primary health care. The promotion of PHC is facilitated when these fundamentals are applied to improve health situation.

This section presents: the concept of PCH, planning of PHC, and the implementation of PHC.

The Concept of PHC

The definition of PHC points to at least five characteristics of PHC. These are: (1) The PHC should reach the needy. It is an essential health care which is based on technology. It has methods which are practical, scientifically sound, and socially acceptable. (2) The PHC services should be acceptable to the community, and involve the participation of the community. (3) The health services must be effective, and available at affordable costs. (4) The PHC services should be integrated with the system of the country. (5) The PHC program should be multi-sectoral in approach. (AKU, 1995; WHO, 2004).

The five characteristics described above, can be actualized provided the essential elements of a PHC program are followed. These components were duly mentioned in the Alma Ata Declaration. The eight elements are: (1) Education concerning prevailing health problems and the methods of identifying preventing, and controlling them. (2) Promotion of food supply and proper nutrition, an adequate supply of save water and basic sanitation. (3) Maternal and child health care, including family planning. (4) Immunizations against the major infection diseases. (5) Prevention and control of locally endemic diseases. (6) Appropriate treatment of common diseases and injuries. (7) Promotion of mental health. (8) Provision of essential drugs. (AKU,1993; Ali, 2001; GOP, 2008-9; WHO, 1978).

The concept of PHC and its ultimate goal to ensure better health for ALL, has been pursued with vigor by the WHO. Five key components were identified in another WHO document. These elements are: (1) Reducing exclusion and social disparities in health. (2) Organizing health services around people’s needs and expectations. (3) Integrating health into all sectors. (4) Pursuing collaborative methods of policy dialogue. (5) Increasing stakeholder participation. (WHO, 2003).

The characteristics and components of PHC emerging from Alma Ata Declaration, provide guidance with regard to planning and implementation of PHC programs.

The Planning of PHC

The planning of PHC is guided by three basic principles. These are: equity, effectiveness, and efficiency. In planning, these principles are kept inter–linked in their application. (WHO, 1978).

Equity: it has two aspects. One, every citizen should be entitled to receive health care facilities. Two, the needs of all individuals should be taken in consideration. However, it does not imply that everyone should receive equal care. The needs of individuals are not equal. Equity calls for health care according to need. (AKU, 1995; Khan, 2009; PMA, 2012; Zaidi, 2005).

Effectiveness: Monitoring of the PHC program is essential. It ensures the effectiveness of the services being offered. Poor effectiveness is reflected in poor health statistics. The effectiveness of program becomes possible only through better health education and dedication of the health staff. (Nayani, 2011: 6-16; WHO, 2008).

Efficiency: The efficiency of the program is realized through efforts at ensuring equity and effectiveness. Efficiency of the program demands that it should be low cost, and yet geared to produce favorable results. (Nayani, 2011: JAMPS, 2010:93-97).

In the planning phase of PHC, the application of principles of equity, effectiveness, and efficiency help to provide health care to all sections of the population. However in the developing countries, including Pakistan, these three principles are often ignored while planning PHC programs. (Helander, 2000; GOP, 1990; Zaidi, 2000).

The Implementation of PHC

The success of PHC programs is seen in the successful implementation of PHC plans. The public health care system of a country is framed according to its resources and needs. The government obtains help from the community and NGOs to ensure sound implementation of health and plans. In the implementation phase of PHC programs, the factor of PHC quality becomes paramount. (Rabbani, 2010; Shaikh, 2003). The role of hospitals and the doctor-patient relationship are crucial factors in the quality of PHC services.

The Role of hospitals in PHC: The PHC approach envisages that the hospitals become responsive to the health needs of the community in their locality. In this context the Aga Khan Foundation (AKF), in collaboration with the WHO, organized a conference in 1981. The recommendations highlighted: (1) the role of hospitals in promoting PHC goals with community participation. (2) The role of hospitals in providing intimate support to PHC in activities. (3) The role of hospitals in motivating health related staff to PHC. (4) The role of hospitals in research related to health services. (AKF, 1981).

The Doctor Patient-Relationship: The implementation of PHC depends on sound relationship between the doctor and his patient. The relationship is influenced by the continued availability and desire of the doctor to serve individual cases in times of need. The quality of comprehensive PHC also depends on the cost involved in obtaining the services of the efficient doctors. (AKU, 1987; USAID, 2011; WHO, 2005).

1.2. SIGNIFICANCE OF THE STUDY

In Karachi, the NGOs are engaged in a number of social services. These include: education, housing, legal aid, health rehabilitation from drugs, sports, and some vocational

Services. (NGORC, 1997; Pasha, 2003, UNDP, 1991; USAID, 2012). The role of NGOs in promoting PHC in Karachi has not received special and focused attention.

The study in hand breaks fresh ground. It is significant on four counts. One, it conducts survey to find and analyze the views of knowledgeable citizen with regards to usefulness of NGOs work in PHC. Two, it examines how well the government and NGOs cooperate in the promotion of PHC. Three, it investigates the current state of cooperation between community and the NGOs. Four, it explores public views concerning the role of NGOs in the improvement of PHC.

The study is likely to be of assistance to stakeholders, engaged in the promotion of PHC in Karachi, and in the country, with the help of NGOs.

1.3. PRIMARY HELTH CARE IN PAKISTAN

The Alma Ata Declaration of 1978 on health was adopted by all the signatory countries to meet health care needs of people. Later the WHO adopted a resolution in 1998 to provide directions for the new global Health for ALL policy. The new policy "Health for ALL in the 21st Century" succeeds the "Health for ALL in the Year 2000". In the new policy, the concept of social justice is explained in key values, goals, objectives, and targets. (Braveman, 1994; WHO, 1978).

The signatory countries have promoted the goals of PHC keeping in view the socio-development state of the country and needs of their citizens. For example, in India the planning of PHC has been done covering "Rural Primary Health Care" and "Urban Primary Health Care". (Gupta and Muhajan, 2005:489-496). The government of Pakistan, however, introduced the PHC services prior to the 1978 Alma Ata Declaration of Health for ALL by the year 2000". (Iliyas and Soomro, 2000:91-96). The progress on PHC goals, for various reasons has not been ideal. A number of constraints on PHC in the country seriously affect the health situation in Pakistan.

This section covers the framework of PHC in Pakistan. Current health situation in Pakistan, and challenges to PHC in Pakistan.

The Framework of PHC in Pakistan

The framework of PHC is structured on Basic Health Units (BHUs), Rural Health Centers (RHCs), and supporting facilities such as dispensaries, maternity and child health centers, and sub-centers. Medical staff is appointed by the Government to ensure smooth functioning of the system. (GOP, 1994)

The Structure of PHC

The structure of PHC provides a systematic link between the village community and the whole health system. In Pakistan, during the period 1978-1983, total of 625 Rural health Centers were planned and 492 were built. A total of 4596 Basic Health Units were planned and 3496 were completed. The budget allocation was inadequate for the completion of the entire planned project. The work on the expansion of PHC services in the country has continued, subject to the availability of funds. Lady Health Workers (LHWs) are at the core of PHC programs. The Family Planning program has received considerable attention in the PHC approach. (GOP, 1994; Iliyas, 2003; Lashari, 2004).

Subject to the spread and density of population, a Basic Health Unit serves 5,000-10,000 population. The services in a BHU include: Maternity and Child Health (MCH) services. Child care, malaria control, immunization, diarrheal disease control, mental health, and school health services. (GOP, 2007).

Five to ten BHUs are linked to a Rural Health Centre. The RHC has facility for X-ray, and provision for minor surgery. The RHC has about 25 beds capacity. The RUC is linked to Tehsil / Talulka Hospital. The hospital at the District Headquarters has all the facilities related to health care. (GOP, 2001).

The PHC programs of malaria control, immunization, diarreahea disease control, and maternity and child health services are among the urgent needs of urban areas as well. The provision of clean water facilities, sewage and sanitation needs, and protection against pollution is the pressing problems of urban areas. These issues fall in PHC domain, and are to be addressed through PHC structure. (GOP, 1991).

The Functioning of PHC

The structure of RHC becomes dynamic and functions through the combined efforts of members of the health team in each centre. Depending on the size of the PHC unit, the health team is provided. The team generally comprises: Medical officer, Nurses, Lady Health visitors, Midwives, Vaccinator, Dispenser, and Administrative Staff. The duties of the team members are mentioned in most studies related to PHC. (Khalid and Iliyas, 1990).

The broad functions of the health team in a center are: Provision of medical care, control of communicable diseases, supply of environmental sanitation, maternal and child health services, health education, and implementing the national health care programs. (GOP, 2008-9).

The scope of comprehensive PHC is considered to be very extensive, and beyond the reach of most developing countries. (Waslh, 1980). The UNICEF, therefore, proposed a selective PHC (SPHC) approach. The SPHC focuses on the selection of a number of limited health programs for implementation. (Cloudia, 2003; Cueto, 2004). For example, the mother and child health lays emphasis on six elements termed GOBI-FF. It stands for: (growth Monitoring), O (ORS), B (breast Feeding), I (Immunization), F (Family Planning), and (Family Education). The effectiveness of SPHC approach has been debated in the literature. (AKU, 1983; WHO, 1978).

The framework of PHC in Pakistan is closely related to the health situation in the country. The threats to health pose problems for the PHC.

Current Health Situation in Pakistan

A number of studies have appeared on the health situation in the country. (Bhutta, 2011; Burki, 2008; Lashari, 2004, WHO, 2010, Zaidi, 1988). K.Z. Hasan in his paper "Health of the Nation: Present Status and Future Prospects" (1999:215-230), described the health situation of the country to be "grim". The current health situation has not shown much progress. The present health data and threats to health in Pakistan indicate serious problems.

The Health Data of Pakistan

The population in Pakistan has increased from 34 million in 1951 to 142.5 million in 2001. It is likely to reach 220 million in 2020, at its present growth rate. (GOP, 2002). The Tables related to health indicators at Appendix B of the study in hand, suggest that present Public Health System is not in a position to meet amply growing health care needs of the country.

The Maternal Mortality is 320 per hundred thousand live births. (WHO, 2010). The infant Mortality Rate is 73 per thousand live births. (WHO, 2010). The crude birth rate is 40, and crude death rate is 11 per thousand populations. (Imran, 2005; WHO, 2010). In Pakistan, the nutritional disorders and infectious diseases are at worst level, when compared to other countries of South Asia. (Arif, 2002; Bhutta, 2011; WB, 2004).

A UNDP sponsored Pakistan National Report entitled "Social Audit of Local Governance and Delivery of Public Services" (UNDP, 2012), provided data on health, drinking water, sewerage and sanitation, and some other social services. During the year 2011-2012, 24 percent respondents reported that they had no access to government health care, Thirty eight percent were dissatisfied, 29 percent were satisfied, and 9 percent indicated that they were neither satisfied nor dissatisfied. For drinking water supply, 32 percent reported no access, 37 percent expressed satisfactions, and 26 percent dissatisfaction and 5 percent were neither satisfied nor dissatisfied. As regards sewerage and sanitation, 22 percent stated no access, 23 percent expressed satisfactions, and 51 percent dissatisfaction and 4 percent were neither satisfied nor dissatisfied. UNDP, 2012).

The data provided by the UNDP, showing the report of no access in health care by 24 percent, in drinking water supply by 32 percent, and in sewerage and sanitation by 22 percent indicates that current situation of health is by no means satisfactory. UNDP, 2012).

Threats to Health in Pakistan

In the literature on health, items that have detrimental effect on health are discussed in great details; Studies on smoking, drugs addiction, and malnutrition which have adverse health effects are common. (AKU, 2005; Imran 2005; Zaidi, 1995). A brief mention may be made of those health threats that may be kept in view in the context of PHC strategy.

Respiratory Diseases: Infections of the respiratory tract and middle ear are considered main cause of infant and child mortality. (Imran, 2005). Some of the causes of respiratory diseases are: tobacco smoking, air pollution, lack of health care resources, lack of sanitary water, and crowded living conditions. (Mahmood, 2003, Zaidi, 2000).

In Pakistan, 51 percent suffer from acute respiratory infection (ARI). In 2006, there were 16,056,000 reported ARI cases. In these cases, 25.6 percent were children under age of five. (USAID, 2012).

Diarrheal Diseases: Infections from diarrhea are a major cause of death among children under the age of five. Nutritional measures against the disease are promotion of breastfeeding and zinc supplementation. In 2006, there were around 4,500,000 cases of diarrhea in Pakistan. (Rabbani, 2010; Syed, 2011).

Controllable Diseases: in these diseases are: (1) Malaria. The infection is transmitted through mosquito bites. The unsanitary condition and stagnant water bodies provide breeding ground for mosquitoes. In 2006 there were about 4,390,000 cases of malaria fever in the country. (GOP, 2010; WHO, 2010). (2). Poliomyelitis. In Pakistan, polio has not been eradicated so for. In 2008, there were a total of 89 reported cases. (WHO, 2010). (3). Cholera. In 2006, a total of 4,610 cases were reported. A recent study suggests that cholera may account for a quarter of all childhood diarrhea cases in some parts of Sindh Province. (USAID, 2012; WHO, 2010). (4). Dengue Fever. In October 2006, cases of dengue fever were observed in the country. Several deaths were caused by the fever. Causes were attributed to initial misdiagnosis, and late treatment. (USAID, 2012; WHO, 2010). (5). HIV/AIDS. HIV is the virus that causes AIDS. The national surveillance data suggest that there are nearly 40,000 HIV positive individuals in the country. (PRCS, 2009; UNO, 2004). The transmission of HIV occurs through: body fluids, unprotected sex, blood transfusions, use of unclean needles, and intravenous drug use. (Faisal, 2006; Lashari, 2004:24; NACP, 2001; Shaikh, 2008; WHO, 2010).

Chronic Diseases: The data suggest that about one in every 9 Pakistani women is likely to suffer from breast cancer. (Imran, 2005). Obesity as a health issue has drawn attention in the country. Type 2 diabetes is associated with obesity. Data indicate that 22.2 percent of individuals over the age of 15 years are inclined towards obesity. (Gulf, 2006).

The health data and threats to health in Pakistan point to serious challenges faced by primary health care planning and implementation.

Challenges to PHC in Pakistan

The literature concerning health care in Pakistan indicates three basic constraints on the promotion of primary health care in the country.

Lack of Political Will

The desire and commitment of society and the government seems totally lacking to improve the health conditions. Total public and private health expenditure in Pakistan hardly exceeds 2-3 percent of Gross Domestic Product. Health care receives low priority in the budget allocation. (Lashari, 2004; Network of Consumer Protection, 2005). Corruption in all echelons of government has serious consequences for primary health care also. (USAID, 2012; WB, 1993).

Lack of political will is evident in the implementation of the health policies. The pharmaceutical industry, mostly in the hands of multinationals, enjoys market power. Essential drugs needs in the primary health care are sold at higher costs under the cover brand names. (One World South Asia, 2013). Policy makers violate the basic principles of equity, effectiveness, and efficiency in the implementation of policies. (Lashari, 2004).The doctors generally remain posted to urban areas. The rural areas and the needs of PHC remain ignored. (Zaidi, 2005).

The Constraints of National Health Policy

Health policy encompasses decisions, plans, and actions that are undertaken to achieve specific health care goals within a society. (Lashari, 2004; Shaikh, 2006). A glance at the health policies of Pakistan of 1990, 1997, and 2001 may show that singleness of purpose is not observed in these policies. There is no continuity in the pursuance of health care goals. (Lashari, 2004; Zaidi, 1995). PHC issues are mentioned, but subsequent achievements and lessons learnt in the implementation of plans are not conspicuous in the health literature.

The promise to improve health services by successive Governments in Pakistan, have remained unfulfilled so far. Most of the attention is given to Curative services. These services mostly meet the needs of urban areas. The preventive services which form part of PHC remain ignored. (Zaidi, 1995). In planning of health services, the integrated approach is not adopted. For example, health-related aspects of agriculture and forestry sectors, which have bearings for health, are not coordinated. (Lashari, 2004).

Research in the Promotion of PHC

The planning and implementation of PHC is kept firmly in the hands of civil servants. Universities and other stakeholders are never involved in any policy making process, and especially health care, in the country. Research is essential for providing a knowledge base related to health problems of the country. Research is also vital for guidance in the implementation of health programs. Presently, funding for health programs and monitoring of the programs has assumed importance. Research provides keys to these needs.

In the promotion of primary health care, the role of NGOs has become significant in Pakistan.

1.4. THE ROLE OF NGOs IN PRIMARY HEALTH CARE

The term "NGO" is considered too broad, a defines and exact definition. Scholars differ, and have given a number of definitions to specify the term. (NGORC, 2000). An NGO is normally taken as an organization which is not associated with government. It usually performs works related to welfare, benefit, and development of society or certain sections of society. It is generally constituted by a body of volunteers. (ADB, 1999; Maria, 2011; NGORC, 1992; Pasha, 2002; TVO, 1993; UNDP; 1997; WB, 1993 ;).

NGO role has considerably increased worldwide. In providing social services to the society. In the United States an estimated number of NGOs is 40,000. (http://www.humanrights.gov). There are 277,000 NGOs in Russia, (Chicago Tribune, 2008) and about 3.3 million in India. (One World Net, 2010 and the Indian Express, 2010). In Pakistan, the civil society is comprised of a diverse and broad range of non-state actors. In this structure, the number of NGOs is estimated at 56,000 (SPDC, 2002) and 100,000 registered and unregistered (USAID, 2011:2). The NGOs in the developed countries enjoy more power, credibility, and access to resources. (Martone, 2012). In the developing countries, including Pakistan, the NGOs have less prestige and are less legitimate in the eyes of international donors. (USAID, 2012; WB, 2004; WHO, 1993-94).

The role of NGOs in the health sector of Pakistan merits due consideration. An estimated 1,074 international and 907 national NGOs are engaged in the health sector for decades. (Maria, 2011). This Section covers: NGOs and primary health care in Pakistan, and Basic Challenges to NGOs in primary health care promotion.

NGOs and Primary Health Care in Pakistan

The NGOs have remained involved in social work in Pakistan since 1947. The creation of Social Welfare department in 1955, gave a boost to the NGO activities in the country. (NGOs RC, 1993; Zia, 1996). During 1980s and 1990s, the number of NGOs has mushroomed. (Pasha, 2002:1-2; UNDP, 1997). The prevailing economic and social inequalities in the country have provided opportunities to NGOs to widen their scope of work. (Pasha, 2002). The NGOs play an important role in creating awareness among the masses, and serve as a pressure group in Pakistan. (Yousuf et al, 2010 :).

The NGOs in Pakistan are mostly engaged in the traditional social sectors. These include: health, education, rehabilitation, and the provision of emergency support. NGO work in the health sector is more focused on maternal and child health, and family planning. (NGORC, 1993; Pasha, 2002). The health care sector in Pakistan continues to have glaring weaknesses. A more concentrated joint efforts are needed by the government, NGOs and the community to remedy the situation. (JAMPS, 2010; USAID, 2012; WHO, 2011; WB, 2004).

Gradually more NGOs are getting involved in the improvement of primary health care needs of water, sanitation, environmental issues, and urban development. (USAID; 2012). The success and achievement of NGOs in the health care sector is not much evident. (WHO, 2005). The situation calls for improvement in the performance of NGOs. Presently the NGOs are reported to have internal problems. They lack: (1) Good governance in some NGOs. Their Board of Directors is seldom changed. (2) Policy for staff capacity building. (3) Coordination among NGOs engaged in a similar project. (UNDP, 1999).

Basic Challenges to NGOs in Primary Health Care Promotion

Apart from internal problems of NGOs in Pakistan, there are some basic issues which impact on the role of NGOs in the promotion of primary health care in the country.

Control and Monitoring of NGOs by the Government

The Government does not seem to exercise balanced control on working of NGOs in the country, and utilize their efforts efficiently. Full knowledge about the number and type of social work of the NGOs is essential for the exercise of control over them. Presently, three types of organizations are engaged in social work. These are: Foreign non-government development organizations, national non-govt. development organizations, and grassroots organizations. (USAID, 2012). The registration laws for these NGOs differ. This creates difficulties in monitoring data of NGOs, and exercising control over them.

NGOs in Pakistan may be registered under the following five laws. (1) The Societies Registration Act 1860. (2) The Trust Act 1882. (3) The Cooperative Societies Act of 1925. (4) The Voluntary Social Welfare Agencies Ordinance 1961. (5) The Companies Ordinance of 1984. The NGOs that are registered and are operating in different provinces under these laws, pose problems for a systematic procedure of control and monitoring of NGO activities. (Maria, 2011:42; NGORC, 1993; Pasha, 2002:4-5; USAID, 2012:2).

The Goals of NGOs and their Legitimacy

The NGOs are prone to guard the interests of donors. This has implications for NGOs enjoying trust and legitimacy in the target community. Scholars have argued on the role of NGOs in the developing countries. Some of these ideas seem valid in the context of Pakistan as well. P. Hollward argued that NGOs pursue an aristocratic form of politics. (Year of book). In the critique of NGOs, they are often seen as: imperialist in nature, have a tendency to fragment local health care system, and are motivated by special interests. (Hollward, 2008; Maria, 2011:5-7).

The Accountability of NGOs

The factor of accountability of NGOs is essential for the success of their role in the promotion of primary health care. The concerns of NGO accountability have increased in the last two decades due to increasing number of cases of corruption. (Anderson, 2011; Gibleman and Gelman, 2001; Hellinger et al, 1987). There is general consensus amongst NGOs and donors, to ensure accountability through evaluation of services provided by the NGOs. (Keystone, 2006). In the literature, it has been emphasized that NGOs in Pakistan need more education, better organization, managerial skills, and accountability to ensure the process of promotion of primary health care services by the NGOs. (WHO, 2011).

A glance at the primary health care programs of major NGOs in Karachi, seems in order to ascertain how they are geared to promote PHC in the city.

1.5. PRIMARY HEALTH CARE PROGRAMS OF SOME NGOs IN KARACHI

Karachi continues to be one of the fastest growing cities in the world. The population of Karachi grew from 387,000 in 1941 to 9, 269,000 in 1998. (DCR, 1998; www.census.gov.pk). Karachi has a compound growth rate of 3.56 percent per year (www.census.govt.pk). In March (March 30, 2013), the estimated population of Karachi is 13.125 million (www.theodora.com/wfb.current/pakistan/pakistan_peoplehtml). With the growth of city, the pressure on health care services has greatly increased.

Against this background, the NGOs in Karachi are striving hard to improve health services, living, and economic conditions of the citizens. A brief mention may be made of the health care programs of some NGOs in Karachi.

The Orangi Pilot Project (OPP)

The Orange Pilot Project (OPP) has been active in the provision of social services in Orangi since April 1980. The success of Low-cost sanitation program of OPP helped her to gain full confidence and trust of the community. Between 1981 and 1993, sewerage service was provided to 72,070 houses out of 94,122. In 1994, more social services programs were introduced. These are: a basic health and family planning program, a program for supervised credit for small family enterprise units, a low–cost housing upgrading program, a school program, a women's work centre program, and a rural development program. (Khan, 1994). Each program was inducted to meet the pressing needs of the community. In these programs, the low-cost sanitation program and the health care programs are noteworthy.

The sanitation program has obvious implications for improvement in the quality of life and health. The implementation of this program involved close support of the community. The interference of bureaucracy and red tape were totally eliminated. Above, all, local material and available technology was utilized. This made the project cost-effective. The health care programs attended to the problems of high incidence of typhoid, malaria, dysentery, diarrhea and scabies in Orangi. The OPP research showed the prevalence of high infant and mother mortality. This aspect was given priority in the health programs. Presently, the health project of OPP called "Khasida" is focused on the primary health care needs of Orangi residents. The LHW's program promotes health education. In addition, emergency medical care is provided to the community. (OPP, 2010).

The OPP follows a research and extension approach to community development. The development strategy of OPP combines the principle of community research, small scale organization, and use of appropriate technology. (Hasan, 1994).

The Aga Khan Foundation (AKF)

The Aga Khan Foundation is engaged in providing wide-ranging social services in Pakistan. A full size separate study is needed to explicate the services related to health provided by the Foundation. The institutions working under the AKF, like the Aga Khan University, are active in the promotion of research related to health. The Department of Community Health Sciences, Aga Khan University has launched an Urban Health Project with focus on Karachi.

A brief mention may be made of the two phases of the Urban Health Project. (AKU, 1996). In the first phase of Urban Health Project, 1985-1996, the Department of Community Health Sciences introduced an undergraduate medical education program. The curriculum of the program centered on the needs of the disadvantaged communities. The program was oriented to meet the demands of primary health care in urban areas. In this phase, the needs of five squatter settlements of Karachi were addressed. The program served a population of 8,000 to 10,000. The focus of the PHC program was kept on the improvement of health status of women, and children under the age of five. Later, the program was extended to cover families also. (AKU, 1983).

A selected group of women was trained to assume the duties of community Health workers. Their training has a lasting role in the continuity of PHC services to the community. The trained workers provided services in immunization, antenatal care, family planning, control of diarrhea, nutritional counseling, monitoring of child growth, and breastfeeding campaign. The program also provided services to 100-150 families in the area. (AKU, 1985). Access to the curative services was made available through the ambulance fleet, working under the program. This service remained accessible to the entire population of 50,000 residents of the area. (AKU, 1996).

The second phase of Urban Health Project, 1994-1999, embarked on a more broad approach to the promotion of PHC aims. (AKU, 1996). The experience gained in the implementation of first phase of the project was critically analyzed and put to use in the process of second phase. The program set out to organize ethnically diverse and marginalized communities. The aim was to provide knowledge related to community empowerment, and mobilization of the community. It served as a catalyst to bring about change. (AKU, 2000; Alam, 1996).

A comprehensive baseline survey was conducted prior to the launching of the phase. (AKU, 1996-98). Due consideration was given to factors like: estimated population density, ethnicity, socio-economic background of the community, occupation of the populace, and the willingness of the community to work with project. Two control and six intervention sites were selected in the 500 squatter settlements. (AKU, 1996).

Target population of about 100,000 was covered in the project. The Community Management Teams were formed to ensure closer control of the implementation process. The teams helped to identify problems and find solutions to them. The entire course of the project ran smoothly. ( AKU, 2000).

The success story of the second phase of the project presents solid achievements. Some of the aspects are: health education of the population, capacity building of the community through workshops, and training of women in various income-generating activities. Efforts were made to inculcate the spirit of self-reliance among the target population. (AKU, 2007).

The project received the support of the donors, through the Aga Khan Foundation. The improvement in the quantity and quality of water, and sanitation received special attention by the Project. (Rehana, 1999; AKU, 1996-98).

Pakistan Red Crescent Society (PRCS)

In the organization of the Society there are 118 health units. The District Branches of the Society provide support to the units. Primary health care services are offered by the health units through the hospitals of the PRCS. The hospitals have trained medical staff to provide curative services also. The services related to PHC include: immunization, reproductive health services, health education, and provision of medicine free of cost.

PRCS health services lay stress on the adoption of preventive measures to ensure better health. Health education sessions spread awareness with regard to measures against communicable diseases, and HIV/AIDS. Emphasis is laid on maintaining clean living environment, and better nutrition. The PRCS approach to catering for PHC needs is simple and practical. A systematic approach is adopted for early detection of breast and cervical cancers. In the health care of women, management of reproductive health issues and infertility receive special attention. (PRCS, 2009).

Health and Nutrition Development Society (HANDS)

HANDS started its social services program with one village in rural Malir back in 1979. The promotion of health, education, and alleviation of poverty in marginalized communities are the basic goals of HANDS. (HANDS, 2006). The social service programs of HANDS have gradually been extended to cover other districts of Pakistan. Presently, more than 9.0 million population is receiving support from HANDS. Among these are 7000 villages of 15 districts of Sindh, and a district of Baluchistan. (HANDS, 2008)

The social services provided by HANDS have received recognition for management standards. These are certified by Pakistan Center of Philanthropy, and Institutional Management Certification Program by the USAID.

The health promotion programs of HANDS are significant. During 2006-2007, different kinds of specialized services were offered to fifteen social service projects in the area. HANDS, in collaboration the City District Government, run a 20-bed hospital in village Jam Kaunda Bin Qasim Town, Karachi. There is a Community Midwifery Training School, and a hostel in the hospital promises. (HANDS, 2007).

The success of PHC programs of HANDS has been evaluated in the Impact Assessment Studies. In 18 villages of Karachi suburbs, Thatta and Matiari 91 percent newborn had normal weight. Only 9 percent had low weight at birth. It is better when compared to 28 percent at the national level. In the intervention areas of HANDS, a marked decline has been recorded in the maternal mortality rate. Trained midwives provide delivery services to 82 percent women.(HANDS, 2011).

Health Oriented Preventive Education (HOPE)

HOPE was registered in 1997 by a team of social workers. They aimed to bring about change in society, and ensure provision of health and education to the populace. Over the years, the network of primary health care services of HOPE has been greatly expanded. The PHC services are provided in Monzoor Colony, Mujahid Colony, and Bilal Colony in Karachi. The network of services extended from Thatta and Dadu districts in Sindh, to areas of Azad Kashmir. The efforts of HOPE have also received support from WHO and UNICEF.

In the health and education services of HOPE, serious attention is given to research. It helps to pinpoint the problems, and find their solution. The PHC services cover: maternal and health care centers (MHCs) in the target locality, immunization services both at MCHs and through mobile teams, and the provision of preventive and curative services. The Centre of Disease Control Pursues measures related to safe water supply, and steps against poliomyelitis, tuberculosis, diarrhea, malaria, and dengue fever. Nutrition advice to mothers, and monitoring of children growth in the population is a priority taken in the PHC services. (HOPE, 2010).

The educational component of HOPE focuses on school education. The curriculum includes imparting of health and citizen education to children.

Health Education and Literacy Project (HELP)

The HELP aims to improve the functional role of Community Health Workers in the promotion of primary health care services. HELP is engaged in PHC activities in Shah Retool, Neelum, Khada, and other colonies of Karachi. The Community Health Workers are responsible to provide health care and education services to the community. They are paid by the target community for their services. Health education imparted by workers, has been instrumental in creating health care awareness among the community. The HELP has contributed to the promotion of PHC goals in the target localities. (HELP, 2007).

The Amman Foundation

The Foundation was registered in 2008 as a non-profit Trust. Amman Foundation is aimed to provide health care services and educational facilities in the target localities. Presently, the facilities provided by Foundation are available in Ibrahim Hyderi, Korangi and others colonies of Karachi.

The health care intervention is under three-pronged approach. (1) The Maternal and Child care is arranged through the trained Lady Health Workers. (2) Amman Telehealth offers medical advice over phone. The curative health care is provided through the Maternal and Child Health Centers. (3) The Amman ambulance service is used to help in emergencies. Lady Health Workers play a central role in Amman PHC facilities. Educational programs focus on children and unemployed youth. (Amman, 2008).

Small Organizations (NGOs/CBOs)

In Karachi both registered and unregistered NGOs are working. Besides big, small community NGOs and CBOs are also working. In each low income area there are approximately 1-5 local organizations. Their activities differ and depend on provisions of funds or on the orientation leaders. These organizations play a major role in provision of services. (Researcher has personally worked with many small and big NGOs, organizations and institutions in the last 30 years). They are working and running hospitals, educational institutes, welfare and charitable clinics. The schools are being run under the educational NGOs and CBOs. Several organizations are now running privately managed nursing homes, nursing schools and colleges. Some influential individuals have managed to get registration and are being operated by a groups or family or a clique. Health institutions include hospital, maternity home, general practitioners, specialists' clinics, blood banks, MCH centers, diagnostic centers, laboratories, and charitable clinics etc.

Some NGOs and CBOs are only working in their localities; they provide emergency support to individuals, mobile health services, ambulance services and organize medical ( general, eye, dental, sugar) camps also manage centers for special persons (mentally retarded and physically handicapped). Many NGOs and CBO operate on community basis. These include Muslims, Christians, Hindus, Bhais, Sikhs, Arians, Punjabi Sudagrans (businessmen), and Memons etc. and provide welfare, concessional health services and activities preferably to their own members. In case of any outsider comes they are charged on market rates or commercial basis. These include Memon organizations like Bantwas, Kutiana, Ishfaq Memorial, Al-Mustafa, Chippa, and many others.

Small NGOs and CBOs also work on Family Planning, Immunization, safe drinking water, cleaning streets, roads of the area, they are sometimes working as middlemen of the big national NGOs, Multilateral and donors' organizations, politicians, local bodies councilors. They get facilities like repair of roads, sewerage, streets lights, sanitation, removal of solid waste, building dumping places for throwing solid wastes. Advocacy and lobbying for the rights (including health) of the low income people is also one aspect of their service.

Big NGOs manage all type of projects including health, PHC etc. for that they are funded by the donors. But for the implementation, they are bound to get support of these local organizations. CBOs and NGOs of low income or squatter settlements have a very strong association with their people. If they do not allow, nobody can enter into most of these areas. In many areas people regard and give weight to their opinion and also follow their decisions. They also provide volunteers in some case to work with the outside organizations. Sometime outsiders hire these volunteers to work for them on a very small amount as honorarium.

Some individuals run clinics in low income areas. These organizations are mostly managed by single person or a vested interest motivated few persons. Most of these person and NGOs / CBOs are not technically sound enough to get funds from the donors, but they are very strong in working with the community and manage to collect funds, donations, and contributions from their members and community. Donors also do not have affection, attraction or support for these people. It is obvious in most of the cases, donors work with big organizations. And most of the funds are being utilized on administration, high salaries and managing infrastructure.

If capacity building, financial support and technical knowhow are provided to these organizations, impact of the work would be remarkable in the field of development and health sector.

1.6 OBJECTIVES, HYPOTHESES, AND VARIABLE

(1) OBJECTIVES

To determine knowledge of families regarding primary health care living in study area of Karachi.

To assess the accessibility and affordability of primary health services by NGOs in target population.

To evaluate the impact of the NGOs primary health care facilities.

To analyze the families practices toward primary health care.

To find the level of services and staff of NGOs engaged in primary health care facilities.

To compare the primary health care services of NGOs and GOs situated in study area.

To investigate the relationship between family size and preference for health treatment.

To explore relationship between monthly income and living facilities.

(2) Hypotheses

Citizens of study area have inadequate knowledge about PHC.

Families are not satisfied with NGOs PHC services.

NGOs services are not affordable by the families

NGOs have adequate health awareness system in their PHC.

The NGOs and GOs fail to provide primary health care to the people.

NGOs promote awareness regarding primary health care among the citizens.

Educational level plays effective role in family health care.

NGOs promote the primary health care in the society.

The family size has a bearing on the preferences for health treatment.

The monthly income is related to the availability of living facilities.

(3) VARIABLES

The present study following are the dependent and independent variables

Independent Variables

Literacy among the community.

Economic status of the families.

Nature of family system.

Housing facilities of the respondents.

Desire of family size.

Desire of better health.

Access to primary health center.

Dependent Variable

Knowledge of primary health care.

Attitude toward primary health care.

Services in NGOs primary health care centers.

Level of citizen's satisfaction with NGOs primary health care.

Assessment of NGOs primary health care system.

1.7. METHODOLOGY OF RESEARCH

The details of methodology of research are provided in chapter 3 of the study. In this section, four salient features of methodology are reported. (1) Research Method: The quantitative research method has been adopted in the study. (2) Universe of the Study: The city of Karachi is the study universe. The City has 5 Administrative Districts, and a total of 18 Towns in the 5 Districts. (3) Sample Size: A sample size of 340 has been selected. The sample size meets the requirements of total population of the City, and the socio-cultural characteristics of population. (4) Collection of Data : The data has been collected using the Questionnaire at Appendix A.

1.8. LAYOUT OF THE STUDY

The study is laid out according to the usual pattern of a Quantitative Research Study. It has 5 chapters: introduction, Review of Related Literature, Methodology of Research, Data and its Analysis, and Conclusions. The study also has the enclosed bibliography.

1.9. KEY TERMS IN THE STUDY

(1) Awareness: Some knowledge of basic health at least for meeting an emergency.

(2) Bad Locality: Poor and shanty areas of the locality.

(3) Basic Health: Health care services which fulfill ones immediate needs.

(4)CBOs: A short form for community based organization. It is basically established in an area for providing services to the community with its own resources by collecting donation.

(5) Family Size: Represents parents and children living in one house and cooking at one place.

(6) Health: A health condition measured by four components, physical, mental, social and spiritual.

(7) Health Facilities: District Health Center, Rural Health Center, Basic Health Unit, general practitioner nearby the locality providing health services and primary health care.

(8) Healthy Conditions: means performing his / her routine activities and able to carry out routine work.

(9) Hypothesis: An informed guess about the answer to a research problem. A research hypothesis predicts a positive relationship between variables so that the hypothesis can be tested and either accepted or rejected.

(10) Less Educated: An illiterate or matriculate person.

(11) Low Income: Income not being sufficient to meet basic minimum needs of the family.

(12) NGOs: Stands for non-governmental organization working voluntarily for providing any service or facility to the community in a particular area.

(13) Null Hypotheses: It is a prediction that no difference will be found from the expected.

(14) Primary Health Care: It is the essential health care which is given at the grass root level. It is initiated with community participation and is appropriate, acceptable and accessible to the community.

(15) Promotion: The promotion of primary health care by NGOs or the public health sector.

1.10 RESEARCH SOURCES:

The works cited in the study are represented in the enclosed bibliography. The enclosed bibliography includes: research studied in the form of books, and papers; conference procedures; research journals; newspaper articles; and encyclopedias.

CHAPTER 2

REVIEW OF RELATED LITERATURE

2.1 SOCIOLOGICAL THEORIES AND THEIR IMPORTANCE

Theoretical Perspective

Sociology emerged as a subject in the middle and late nineteenth century. It was a time of rapid change in European societies. It is a professional branch of social science. It is a theoretical as well as practical discipline. From the beginning of the subject, sociologists have been presenting their perceptions and practical observations. Theory is a general statement about how some parts of the world fit to one another. (Henslin, 1997:20).

Relative to other intellectual disciplines sociology lacks a single, integrated perspective, there’s no one key historical figure who served as a "fountainhead", for the discipline, like Darwin in biology and Freud in psychology and Newton in Physics. Rather sociology is characterized by a relatively large number of theories that to varying degrees are in cooperation with one another. Marx and Weber in the nineteenth century and Parsons in the twentieth came to the closest being key figures as bench marks for ranking out that the differences in approaches. More has crystallized a majority of sociologists into a dominant school. (Twaddle, 1987:24-34)

Sociologists analyze social phenomena at different levels and from different perspectives. From concrete interpretations to sweeping generalizations of society and social behavior, sociologists study everything from specific events (the micro level of analysis of small social patterns) to the "big picture" (the macro level of analysis of large social patterns). The pioneering European sociologists, however, also offered a broad conceptualization of the fundamentals of society and its workings. Their views form the basis for today's theoretical perspectives, or paradigms, which provide sociologists with an orienting framework—a philosophical position—for asking certain kinds of questions about society and its people.

This is not to say that there is no common ground among sociologists. There are a number of Meta theoretical positions that most sociologists would agree on at least broadly. Most Sociologists today employ three primary theoretical perspectives. These perspectives offer sociologists theoretical paradigms for explaining how society influences people, and vice versa. Each perspective uniquely conceptualizes society, social forces, and human behavior. These arise from the historical and political (ideologists) roots of the discipline in the nineteenth century. (Twaddle, 1987:24).

Historical Roots

The emergence of sociology was a result of the scientific knowledge, empirically verifiable, and developed in the natural sciences. (Henslin,1995). Sociology took shape when the doctrines of positivism had been consolidated and there were rapid and exciting development in science. One important development was an emerging attempt to apply scientific procedures to the study of human behavior. Adopting the view of the world from the physical sciences, early sociology also developed a number of deterministic and mechanical models of society. Durkheim saw social facts as existing sui generis as collective conscience or body of norms that determine the behavior of individuals in the society. The social Darwinists applied Darwin’s theories as evolution to the social order and saw social arrangement as part of a natural evolutionary process. (Hofstadler, 1995; Sumner ,1961). The major counter to the rise of positivism was the German tradition of idealism, which dominated the intellectual style of historical work. (Parsons, 1937). Idealists asserted that there were no laws of human nature. All that existed of reality was human conceptions of reality.

Sociology can be seen as a field that has wrested from its beginning with the conflicts between these competing historical view points. Marx in his early writings emphasized the humanistic traditions. Weber acknowledged the importance of economic forces. Parson tried to resolve the conflicts by focusing on the subject matter of the idealists’. Radically positivism and radically idealist theories can still be found in sociology.

Political Roots

Nineteenth century was the time of political ferment. The emerging commercial middle class, committed to non-interference with profit making, developed ideology of laissez-Faire capitalism. Spencer was regarded as one of the founder of sociology. Provided view of society that the idea of laissez-Faire capitalism. He was of the views that societies naturally evolved from simple to complex forms of organizations. It was a natural phenomena. The job of the state was not to foster or alter or accelerate progress. The job of the state was to safeguard the individual rights of the citizens and not to interfere with social arrangements or try to introduce change. (Martindale, 1960 and; Turner, 1978). Under this point of view that government should be limited to certain essential services that cannot be provided or supplied by private enterprise. The public good demanded that business be unfettered by regulation. The workers situation was grim, long hours, low pay, factories dangerous. The worker was alienated from his labor. People in these circumstances tended to favor restrictions on the activity of the capitalists either through govt. regulation of business or through a reallocation of power in which workers would become the owners of the means of production. Hence the ideology of socialism was born. (Engels, 1973; Ludz,1973 Marx, 1961). Political ideologies of the nineteenth century had a profaned influence on the development of sociology and still have an influence on modern theory and research. (Twaddle, 1987:25).

Theory of Symbolic Interactions

The symbolic interactions perspective, directs sociologists to consider the symbols and details of everyday life, what these symbols mean, and how people interact with each other. Although symbolic interactions traces its origins to Max Weber's assertion that individuals act according to their interpretation of the meaning of their world.

According to the symbolic interactions perspective, people attach meanings to symbols, and then they act according to their subjective interpretation of these symbols. Verbal conversations, in which spoken words serve as the predominant symbols, make this subjective interpretation especially evident. The words have a certain meaning for the "sender," and, during effective communication, they hopefully have the same meaning for the "receiver." In other terms, words are not static "things"; they require intention and interpretation. Conversation is an interaction of symbols between individuals who constantly interpret the world around them. Of course, anything can serve as a symbol as long as it refers to something beyond itself. Thus, symbolic integrationists give serious thought to how people act, and then seek to determine what meanings individuals assign to their own actions and symbols, as well as to those of others.

To better understand symbolic interactions, let us try to explain it by understanding the meaning of symbols. The important aspect of the medical practice is symbolic interaction between doctor and patient. The patient expects the doctor to give a warm welcome. The physicians all over the world are viewed by the patients.

Theory of Functional Analysis:

The central idea of functional analysis is that society is a whole unit, it is up of interrelated parts that work together. Society functions smoothly when various parts work together in harmony. When all the parts of society fulfill their functions, society is in a "normal" state. If they do not fulfill their functions, society is in an "abnormal" or "pathological" state. Functionalists say that we need to look that both structure (how the parts of society fit together to make the whole) and function.

Functions can be either manifest or latent. If an action is intended to help some part of a system, it is a manifest function. From the perspective of functional analysis, the group is a functioning whole, with each part related to the whole. Whenever we examine a smaller part, we need to look for its functions and dysfunctions to see how it is related to the larger unit.

With new laws governing medical schools and hospitals, institutionalized medicine grew more powerful, and care of the sick gradually shifted from the family to outside multiplied, care of the aged changed from a family concern to a government obligation.

According to the functionalist perspective, each aspect of society is interdependent and contributes to society's functioning as a whole. The government, or state, provides education for the children of the family, which in turn pays taxes on which the state depends to keep itself running. That is, the family is dependent upon the school to help children grow up to have good jobs so that they can raise and support their own families. In the process, the children become law-abiding, taxpaying citizens, who in turn support the state. If all goes well, the parts of society produce order, stability, and productivity. If all does not go well, the parts of society then must adapt to recapture a new order, stability, and productivity. For example, during a financial recession with its high rates of unemployment and inflation, social programs are trimmed or cut. Schools offer fewer programs. Families tighten their budgets. And a new social order, stability, and productivity occur.