The invisible worker: The role of the peon in Nepal's health service

Health services are most effective when tailored to fit the needs of particular populations. Thus, an underlying assumption is that social and cultural factors are fundamental to adequate health planning. To understand what socially relevant information is used, or perceived as being useful by policy makers, a study was made of the decision-making process involved in planning the rural health program in Nepal. Community participation in developing primary health care is a priority in this program. Despite the fact that planners are presently designing programs for community health volunteers, they are unaware of, or fail to utilize, social and cultural factors which affect local health care delivery. In Nepal, the peon, the lowest ranking worker in the health bureaucracy, performs many basic and crucial functions in the delivery of health services at the local level, such as dispensing medicine, dressing wounds and giving injections. In addition, he is the only worker who is actually from the village, who speaks the local dialects and has the most interaction and direct contact with patients. Rather than investigate who these peons are and what motivates them to assume voluntarily these same functions being proposed for the newly created community volunteer, their contribution is unrecognized and remains invisible to foreign and Nepalese health planners. This research bears out earlier observations that social and cultural data are not being used by most health planners dealing with Nepal. But even more significant, when planners are aware of social factors that affect health services, it does not appear to influence the planning of the rural health program. When a truly community based health worker arises, there are no mechanisms to change the established structure or procedures to take advantage of this fact. This illustrates the barriers within the bureaucracy to incorporating socially relevant information in health planning.